What is the rescue dose rate for Levophed (norepinephrine)?

Levophed (Norepinephrine) Rescue Dosing

For rescue dosing in acute hypotension or shock, start Levophed at 8-12 mcg/min (2-3 mL/min of standard 4 mcg/mL dilution), then titrate to maintain systolic blood pressure 80-100 mmHg, with average maintenance doses of 2-4 mcg/min and maximum doses occasionally reaching 68 mg/day in refractory cases. 1

Standard Preparation and Initial Dosing

• Dilute 4 mg (4 mL vial) in 1,000 mL of 5% dextrose solution to create a 4 mcg/mL concentration 1
• Start with 8-12 mcg/min (2-3 mL/min) as the initial rescue dose 1
• Administer through a large central vein using a plastic IV catheter to minimize extravasation risk 1

Titration Strategy

• Titrate to achieve systolic blood pressure of 80-100 mmHg sufficient to maintain vital organ perfusion 1
• In previously hypertensive patients, raise blood pressure no higher than 40 mmHg below their baseline systolic pressure 1
• Average maintenance dose: 2-4 mcg/min (0.5-1 mL/min) after initial stabilization 1

High-Dose Scenarios

• Doses as high as 68 mg base (17 vials) per day may be necessary in patients with persistent hypotension 1
• When high doses are required, always suspect and correct occult blood volume depletion first 1
• Central venous pressure monitoring is helpful for detecting hypovolemia in patients requiring escalating doses 1

Pediatric Rescue Dosing

• Pediatric IV infusion: 0.1-1.0 mcg/kg/min for continued shock after volume resuscitation 2
• Start at the lowest dose and titrate to desired clinical effect 2
• Doses as high as 5 mcg/kg/min are sometimes necessary in pediatric patients 2

Critical Pitfalls to Avoid

• Never administer in saline solution alone—must use dextrose-containing solutions to prevent oxidation and loss of potency 1
• Always correct blood volume depletion before or concurrent with vasopressor administration 1
• Avoid abrupt withdrawal—reduce infusions gradually once adequate blood pressure is maintained 1
• Have phentolamine 0.1-0.2 mg/kg (up to 10 mg) diluted in 10 mL normal saline available for extravasation, injected intradermally at the site 2

Duration and Monitoring

• Continue infusion until adequate blood pressure and tissue perfusion are maintained without therapy 1
• Treatment duration varies widely—some cases of vascular collapse from acute MI required up to 6 days of therapy 1
• Use an IV drip chamber or metering device to accurately measure flow rate in drops per minute 1

Concentration Adjustments

• If large fluid volumes are needed, use a more dilute solution (<4 mcg/mL) to avoid excessive pressor doses 1
• When fluid restriction is necessary, concentrations >4 mcg/mL may be used 1

Cardiac Arrest Context

• In cardiac arrest, norepinephrine is used at the same dosing as for acute hypotensive states after effective heartbeat and ventilation are established 1
• The beta-adrenergic stimulation increases strength and effectiveness of systolic contractions once they occur 1