What is the dose of Norepinephrine (Levophed) for hypotension?

From the Guidelines

Levophed (norepinephrine) for hypotension is typically started at 0.1-0.5 mcg/kg/min via continuous IV infusion, as recommended by the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. The dose should be titrated every 5-10 minutes to maintain a target mean arterial pressure (MAP) of 65-70 mmHg or as clinically indicated. Key considerations for the use of Levophed include:

• Administration through a central venous catheter whenever possible to avoid extravasation, which can cause severe tissue damage
• Dilution in D5W or normal saline to a concentration of 4-16 mcg/mL
• Continuous blood pressure monitoring, preferably with an arterial line for accurate readings
• Weaning the dose gradually to prevent rebound hypotension once the patient stabilizes
• Addressing the underlying cause of hypotension while Levophed provides temporary hemodynamic support It's also important to note that norepinephrine is recommended as the first-choice vasopressor for the treatment of sepsis-induced hypotension, with a target MAP of 65 mmHg, as per the 2016 Surviving Sepsis Campaign guidelines 1. Some key points to consider when using Levophed include:
• The maximum dose is generally 2-3 mcg/kg/min, though higher doses may be used in refractory cases
• Levophed works by stimulating alpha-1 adrenergic receptors in blood vessels, causing vasoconstriction and increasing blood pressure
• It also has some beta-1 activity that supports cardiac output
• The use of Levophed should be guided by the patient's clinical response, with careful monitoring of blood pressure, cardiac output, and other relevant parameters.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Norepinephrine Bitartrate Injection is a concentrated, potent drug which must be diluted in dextrose containing solutions prior to infusion. 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 Give this solution by intravenous infusion. Insert a plastic intravenous catheter through a suitable bore needle well advanced centrally into the vein and securely fixed with adhesive tape, avoiding, if possible, a catheter tie-in technique as this promotes stasis An IV drip chamber or other suitable metering device is essential to permit an accurate estimation of the rate of flow in drops per minute 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 average maintenance dose ranges from 0. 5 mL to 1 mL per minute (from 2 mcg to 4 mcg of base).

The initial dose of Levophed for hypotension is 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute. The average maintenance dose ranges from 0.5 mL to 1 mL per minute (from 2 mcg to 4 mcg of base). The dose should be titrated according to the response of the patient to establish and maintain a low normal blood pressure, usually 80 mm Hg to 100 mm Hg systolic 2.

From the Research

Levophed Dose for Hypotension

• The provided studies do not directly mention the use of Levophed (norepinephrine) for hypotension in a specific dose, but they do discuss the use of norepinephrine as a vasopressor in various shock states 3, 4, 5, 6.
• According to the study published in Annals of translational medicine, norepinephrine is the first-line vasopressor in septic shock, and increasing the dose up to ≥1 µg/kg/min could be an option in cases of refractory hypotension 3.
• The study published in Intensive care medicine states that norepinephrine is the first-choice vasopressor in vasodilatory shock after adequate volume resuscitation, but does not specify a particular dose 4.
• The Journal of veterinary emergency and critical care publication recommends norepinephrine as the first-choice vasopressor to maintain a mean arterial pressure ≥65 mm Hg, but does not provide a specific dose for Levophed 5.
• The Journal of emergency medicine review discusses the clinical use of vasopressors, including norepinephrine, in various shock states, but does not provide a specific dose for Levophed 6.
• The study published in Expert opinion on pharmacotherapy discusses the treatment of orthostatic hypotension, but does not mention the use of Levophed or norepinephrine in this context 7.