Push-Dose Levophed (Norepinephrine) for Acute Hypotension
Push-dose levophed (norepinephrine) is not a standardized or recommended practice in current clinical guidelines, as norepinephrine is primarily administered as a continuous infusion through central venous access for hypotension management.
Understanding Norepinephrine Administration
- Norepinephrine is a potent vasopressor with high affinity for α-receptors, used to increase systemic vascular resistance in hypotensive states 1
- According to FDA labeling, norepinephrine should be diluted in dextrose-containing solutions and administered as a continuous infusion, not as push doses 2
- Standard dosing for norepinephrine infusion is 0.2 to 1.0 μg/kg/min, typically initiated after fluid resuscitation has been attempted 1
Proper Administration of Norepinephrine
- Norepinephrine should be administered through a central venous catheter whenever possible to avoid extravasation and tissue damage 2
- The FDA-approved administration protocol involves adding 4 mg (4 mL) of norepinephrine to 1,000 mL of 5% dextrose solution, creating a concentration of 4 mcg/mL 2
- Initial infusion rates typically start at 2-3 mL/minute (8-12 mcg/minute) and are titrated based on blood pressure response 2
- Maintenance doses typically range from 0.5-1 mL/minute (2-4 mcg/minute) 2
Concerns with Push-Dose Administration
- Push-dose vasopressors carry risks of:
Alternative Push-Dose Vasopressors
- While push-dose norepinephrine is not standardized, push-dose epinephrine (10-20 μg IV every 2 minutes) has been studied in critical care transport settings for temporary management of hypotension 3
- Push-dose phenylephrine has been studied in emergency settings with doses of 50-200 μg IV to temporarily increase blood pressure 4, 5
- Push-dose vasopressin (1 unit IV) has been reported as an alternative for temporary management of hypotension in septic shock 6
Clinical Context for Vasopressor Use
- Vasopressors are indicated when the combination of inotropic agents and fluid challenge fails to restore adequate arterial pressure and organ perfusion 1
- In cardiogenic shock, vasopressors should be used with caution and only transiently, as they may increase afterload of a failing heart 1
- Norepinephrine is favored in situations with low blood pressure related to reduced systemic vascular resistance, such as septic shock 1
Important Considerations
- Early administration of norepinephrine in severely hypotensive septic patients can increase cardiac output through improved cardiac preload and contractility 7
- If rapid blood pressure support is needed before central access is established, other options like peripheral inotropes (dilute solution of epinephrine) should be considered 1
- For bridging therapy until continuous infusion can be established, push-dose epinephrine or phenylephrine may be safer alternatives based on available evidence 3, 4
Remember that vasopressor therapy should be used judiciously and with appropriate monitoring, as these medications can significantly impact morbidity and mortality when used incorrectly.