From the FDA Drug Label
Average Dosage: Add the content of the vial (4 mg/4 mL) of LEVOPHED to 1,000 mL of a 5 percent dextrose containing solution. Each mL of this dilution contains 4 mcg of the base of LEVOPHED High Dosage: Great individual variation occurs in the dose required to attain and maintain an adequate blood pressure. In all cases, dosage of LEVOPHED should be titrated according to the response of the patient Occasionally much larger or even enormous daily doses (as high as 68 mg base or 17 vials) may be necessary if the patient remains hypotensive, but occult blood volume depletion should always be suspected and corrected when present.
The maximum dose of Levophed is 68 mg base per day, as stated in the label, but the dosage should be titrated according to the response of the patient 1.
From the Research
The maximum dose of Levophed (norepinephrine) is typically 3 mcg/kg/min, though there is no absolute maximum dose in life-threatening situations.
Key Considerations
- Levophed is typically started at 0.1-0.2 mcg/kg/min and titrated upward based on blood pressure response, with most patients responding to doses between 0.05-1 mcg/kg/min 2.
- When administering Levophed, it must be given through a central venous catheter as a continuous infusion, never as a bolus.
- The medication should be diluted in D5W or normal saline, and blood pressure should be monitored continuously during administration.
- Careful monitoring for extravasation is essential as it can cause severe tissue necrosis.
- Levophed works by stimulating alpha-adrenergic receptors in blood vessels, causing vasoconstriction and increasing blood pressure in hypotensive states such as septic shock, neurogenic shock, or other vasodilatory shock states.
- As the dose increases, the risk of adverse effects like arrhythmias, myocardial ischemia, and end-organ hypoperfusion also increases.
Clinical Context
- Norepinephrine has wide applicability and is a reasonable first-line agent for shock of uncertain etiology 2.
- The use of vasopressors is more controversial in hypovolemic shock, as the preferred treatment is correction of the volume deficit 2.
- Evidence for vasopressors is limited in cardiogenic shock, but norepinephrine may be preferred over epinephrine in patients with cardiogenic shock, particularly after myocardial infarction 3.
Important Considerations
- Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states 2.
- Keeping a broad differential when hypotension is refractory to vasopressors may help to identify adjunctive treatments in physiologic states that impair vasopressor effectiveness 2.