From the FDA Drug Label
Restoration of Blood Pressure in Acute Hypotensive States Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, LEVOPHED can be administered before and concurrently with blood volume replacement After observing the response to an initial dose of 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute, adjust the rate of flow to establish and maintain a low normal blood pressure (usually 80 mm Hg to 100 mm Hg systolic) sufficient to maintain the circulation to vital organs
The answer to when to start levophed with MAP under 60 is not directly stated in the label. However, based on the information provided, levophed can be administered when intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia.
- The goal is to establish and maintain a low normal blood pressure (usually 80 mm Hg to 100 mm Hg systolic) sufficient to maintain the circulation to vital organs.
- Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered.
- The label does not provide a specific MAP value for initiating therapy, but it implies that levophed can be started in acute hypotensive states when blood pressure is not sufficient to maintain circulation to vital organs 1.
From the Research
Levophed (norepinephrine) should be started promptly when MAP remains under 60 mmHg despite adequate fluid resuscitation, with a target MAP of at least 65 mmHg, as recommended by the most recent and highest quality study 2.
Key Considerations
- The typical starting dose is 0.01-0.05 mcg/kg/min, administered through a central venous catheter, and titrated every 5-15 minutes to maintain the target MAP.
- Before initiating Levophed, ensure the patient has received at least 30 mL/kg of crystalloid fluids unless contraindicated.
- Continuous blood pressure monitoring is essential during administration, preferably with an arterial line.
- Levophed works by causing peripheral vasoconstriction through alpha-1 adrenergic receptor stimulation, effectively increasing systemic vascular resistance and blood pressure.
Important Details
- The maximum dose is generally 3.3 mcg/kg/min, though most patients respond at lower doses.
- Be vigilant for extravasation, which can cause tissue necrosis, and monitor for tachyarrhythmias, especially in patients with cardiac disease.
- Once the patient stabilizes, Levophed should be weaned gradually to prevent rebound hypotension.
Evidence-Based Recommendation
The recommendation to start Levophed when MAP remains under 60 mmHg is based on the most recent and highest quality study 2, which emphasizes the importance of rapid diagnosis and management of sepsis and septic shock. This study suggests that a target MAP of at least 65 mmHg is appropriate, and that norepinephrine is the recommended first-line vasopressor.
Additional Considerations
- Other studies, such as 3 and 4, also support the use of norepinephrine as a first-line vasopressor in septic shock, but the most recent and highest quality study 2 takes precedence in guiding clinical decision-making.
- The study 5 provides additional context on the management of mean arterial pressure in critically ill adults receiving vasopressors, but its findings do not alter the primary recommendation to start Levophed when MAP remains under 60 mmHg.