From the Guidelines
Enteral feeding can be continued in patients on levophed (norepinephrine) if they are hemodynamically stable, with no specific dosage being a definitive contraindication. The decision to initiate or continue enteral nutrition should be individualized based on the patient's overall clinical status, rather than the specific vasopressor dose 1. Patients on low to moderate doses of norepinephrine, such as a starting dose of 0.5 mg/h and increased every 4 hours by 0.5 mg/h to a maximum of 3 mg/h, who have stable or improving hemodynamics, can often tolerate enteral feeding. However, caution is warranted in patients requiring escalating vasopressor doses or those with signs of intestinal hypoperfusion. Some key points to consider when deciding on enteral feeding in patients on levophed include:
- Hemodynamic stability: Patients who are hemodynamically stable can often tolerate enteral feeding, even while on norepinephrine 1.
- Vasopressor dose: While there is no specific dosage that contraindicates enteral feeding, patients on low to moderate doses of norepinephrine are more likely to tolerate enteral feeding.
- Signs of intestinal hypoperfusion: Patients with signs of intestinal hypoperfusion, such as abdominal distension, high gastric residual volumes, or absent bowel sounds, may require temporary holding of feeds and reassessment.
- Benefits of early enteral nutrition: Early enteral nutrition provides important benefits, including maintaining gut barrier function and reducing infection risk, and should be considered in critically ill patients 1. In terms of specific management, starting with low-volume trophic feeding (10-20 mL/hr) and monitoring for tolerance before advancing is a reasonable approach. If concerns about intestinal perfusion arise, temporarily holding feeds and reassessing is appropriate. The key is to regularly evaluate the patient's hemodynamic status, vasopressor requirements, and signs of feeding tolerance, rather than relying on a specific norepinephrine dose threshold 1.
From the Research
Dosage of Levophed for Enteral Feeding
- The dosage of Levophed (norepinephrine) that allows for enteral feeding is not strictly defined, but studies suggest that doses of 0.14 μg/kg/min or less may be tolerated 2.
- A study found that patients with septic shock who received norepinephrine-equivalent doses of 0.14 μg/kg/min or less were more likely to tolerate enteral nutrition 2.
- Another study proposed the use of a mean arterial pressure (MAP)/norepinephrine equivalent dose (NEQ) index to predict the optimal time to initiate enteral nutrition in patients with shock on vasopressors, with a threshold of 417 mmHg·μg·kg·min-1 3.
- However, a review of the literature found that there are many controversies about the safe dose of vasopressors for the initiation of enteral nutrition, and it was not possible to identify a cutoff value for the beginning therapy 4.
Factors Affecting Tolerance of Enteral Nutrition
- The tolerance of enteral nutrition in patients receiving vasopressors is influenced by factors such as the dose of vasopressor, the presence of hemodynamic instability, and the patient's overall clinical condition 5, 2, 4.
- A study found that patients who initiated enteral nutrition within 48 hours of starting vasopressor therapy were more likely to tolerate enteral nutrition 2.
- Another study found that the vasoactive-inotropic score (VIS) did not differ between patients who received enteral feedings and those who did not, except on day 1 6.
Safety of Enteral Feedings in Critically Ill Patients
- Enteral feedings in critically ill patients receiving vasoactive agents are generally considered safe, with no difference in gastrointestinal outcomes and a tendency towards lower mortality 6.
- However, the decision to initiate enteral nutrition in patients receiving vasopressors should be made on a case-by-case basis, taking into account the patient's individual clinical condition and the potential risks and benefits of enteral nutrition 5, 4.