Max on Levophed?

meandragonbrett · Jan 1, 2012

While your hospital might have a policy that states that the max infusion is 40mcg/min....your physician is correct in that there is no physiological max dose of the drug.

BelgianRN · Jan 1, 2012

In our facility we use levophed as a primary choice of vasopressor. However there is no maximum dosage that I'm aware of. 40 µg/min is a rather frequent dose for our deep shock patients. Generally we start adding second, third and fourth pressors when our levophed reaches in the 80 µg/min range.

I generally try to use a few arguments when our intensivists seem reluctant to add a different pressor. I'll sum up the ones I frequently use.

Levophed isn't working at it's maximum proficiency in an acidotic body and vasopressin is.

I remember reading somewhere that Neo gives relatively more venous vasoconstriction thus increasing preload somewhat more than levophed does. Sometimes that can convince them to add Neo instead of pusing more levophed.

Neo gives purely alpha adrenergic activity as opposed to the added beta adrenergic activity of levophed. I generally use that argument when the rhytm of my patient is pushing the 130's and higher.

Another one of my favourites to get vasopressin on board is referring to the fact that levophed increases pulmonary vascular pressure more than vasopressin does.

If everything fails I'll ask for epi and neo and tell them I like the colors on the syringes, respectively bright red and flashy pink, looks way more impressive at the bed side. Not sure how scientifically valid this argument is, but sometimes our lovely doctors take pitty and give the order anyway. As long as I get my way I'll play the clown ^^.

If you feel you are not managing with levophed alone and they stay reluctant to add a second pressor you could always ask if they want to start glucosteroids. They are proven to be effective in upregulating the beta receptors especially in septic shock thus increasing the effectiveness of your pressors a lot.

To get back to the topic at hand. I've heard of other facilities in Belgium and the Netherlands that are very rigid in their management and stick to levophed all the way and never add a second pressor. Their general claim seems to be it's not scientifically proven that adding other pressors increases long term survival or quality of life. However my personal take on this is if you have the choice of instant death or at least getting in a somewhat better condition by adding more pressors I am in favourite of adding more pressors.

Anyway that's my take on it.

RedCell · Jan 1, 2012

Sounds like you are dealing with some variation of septic shock. This game is about MAP and preservation of end organ perfusion. There is no "Max" dose of norepinephrine. It is just a nursing myth similar to renal dose dopamine. Your doc was correct and he was referring to mostly observational studies done in the late 1990's up to present day. Norepinephrine has also been shown in some research to reduce mortality and protect end organ perfusion more efficiently than other pressors available.

When you are up to 40mcg/min of norepi or higher, what else can you give that is going to press the patient more?? Okay, hang some vasopressin. You most likely will see a higher MAP because you are shunting more blood from the periphery back to central perfusion, but what do you think splanchnic perfusion looks like? The kidneys turn into the Sahara and the gut will be dead.

It would be interesting to know the pH and SID in this patient. Receptor sites for pressors and inotropes do not work so well after you start dropping below 7.1. Sometimes Jesus wins and protoplasm loses.

Here is a retrospective study that looks at conservative vs liberal use of pressors in septic patients. Liberal vs. conservative vasopressor use ... [intensive Care Med. 2008] - PubMed - NCBI

sapphire18 · Jan 1, 2012

Our hospital policy max for levophed is 12, which I have always thought is ridiculous. If your hospital or ICU POLICY says you cannot go above 40 mcg/min then you can't, even with an MD order. I've gotten in trouble for just that in the past bc I thought it was ok with a doctor's order.Also I'd be interested in hearing about the renal dosing of dopamine thing...haven't heard about that being a myth.

RedCell · Jan 1, 2012

Our hospital policy max for levophed is 12, which I have always thought is ridiculous. If your hospital or ICU POLICY says you cannot go above 40 mcg/min then you can't, even with an MD order. I've gotten in trouble for just that in the past bc I thought it was ok with a doctor's order.Also I'd be interested in hearing about the renal dosing of dopamine thing...haven't heard about that being a myth.

Low-Dose Dopamine in Patients with Renal Dysfunction:

No Benefit

http://www.turner-white.com/memberfile.php?PubCode=jcom_feb01_orrrenal.pdf

"Renal Dose" Dopamine in Surgical Patients Dogma or Science? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1191298/pdf/annsurg00014-0022.pdf

Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Meta-analysis: low-dose dopamine increases ur... [Ann Intern Med. 2005] - PubMed - NCBI

Guest193822 · Jan 1, 2012

Levophed max is 40mcg/min. I've worked in some hospitals that will not allow over 20mcg/min & a order is required to go above this. I recently worked in an hospital where the Pt was on 75mcg/min with a Vasopressin at 0.02U/min. Of course the pt's in septic shock but my Maps were lingering between 60-65. I eventually did go up on the Vasopressin.

usalsfyre · Jan 2, 2012

Levophed max is 40mcg/min

An endogenous hormone has a max? Nifty....

Epinephrine, dopamine, norepinephrine, vasopressin, ect are generally not considered to have a physiologic max, only a point at which it's time to move on to something else because more isn't going to help that much.

Sugarcoma, RN · Jan 2, 2012

Just had a similar experience myself at 50 of levo and 0.04 of vaso. Was told by the doc there was no max and that he would have me hang it wide open if need be, even though policy states max is 20.

Esme12, ASN, BSN, RN · Jan 2, 2012

Levophed Official FDA information, side effects and uses.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1981284/pdf/brmedj03234-0045.pdf case appears to have been reported(Wolff, 1954). The following case report .... levophed do not appear to recommend a maximum strength exceeding ...an article from 1954.

I had heard this before... I have heard MD's say that if levophed does not help them they will die." For many years we have called this drug in ICU circles as "Leave Em Dead, Levophed" as it was considered as a option after "lesser" meds have failed or as a "Last ditch effort" to save someone's life. I have seen just a straight Epi drip be used when Levo has failed as we all know sick hearts love Epi. Although they are similar......they are vastly different. Many drugs have a "max" amount not just because they are dangerous but because if you are using that much of a drug....it's time to move on and/or it is no longer effective at that amount. Example....Some MD's feel that if you are still having chest pain with nitro at 100 mgs.....don't bother going any higher...they obviously need a different intervention and this drug is not one of them. I think the bigger point here is that if your facility has a policy that you can't titrate over a certain amount then you must abide by the policy. You can be fired for not following policy and procedure and if something goes wrong and the facility is sued you are vulnerable to both being sued and the board because you failed to follow policy and procedure. "He (the MD) yelled at me" will NOT save you from firing and being sued and possibly losing your license.

Example: A very long time ago in a ICU I knew a very smart experienced RN whom I admired very much. We had a very sick, very young male patient that was dying and critical. He was a truck driver who had a ruptured appendix, came to the ED and emergency surgery and recovered well....until they day of discharge. He was getting dressed and suffered cardiac arrest due to (it was found) MASSIVE pulmonary Emboli. There was this surgeon who was a bit of a cowboy (I used to say he'd operate on a three day old road kill for the billable expenses) took this coding (in pulseless electrical activity, EMD,PEA) to the OR removed the clots and placed him on bypass to support the patient while he operated.

They could not remove the man from pump and he returned to ICU on ventricular device. Needless to say when the (OOT) family saw him they were outraged and were going to sue. One day this poor man coded yet again. The MD was at the bedside not by the A-line and wanted intra-arterial epi given. We had seen anesthesia give it, the surgeon give it, and it bought a few more hours. There was no MD by the A-line and the MD was screaming "GIVE IT" the supervisor said no (the MD had adopted a hands off approach since the family wanted to sue) U

ltimately, against explicit policy...the nurse gave it, the patient still died. The family sued, she got fired and brought to the board, she lost her license...at the time her malpractice wouldn't protect her as she was "reckless" she lost everything. She ultimately died shortly thereafter....some say sepsis, freak MI, I say she died from a broken heart.

Morale of the story....follow policies and if that MD won't give orders go to the department head, supervisor and manager. BUt don't act against policy. That MD could care less what happens to you.

I hope you find the information helpful. https://online.epocrates.com/u/10a1571/Levophed

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Epinephrine (Adrenalin): Description: A hormone produced by the adrenal gland (attached to the kidneys) and synthesized commercially. It is employed therapeutically as a vasoconstrictor, as a cardiac stimulant, and to relax bronchioles. It is also used to treat asthmatic attacks and treat anaphylactic shock.

Vasopressors and Inotropes

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[TD][h=2]Epinephrine[/h]

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[TD]Dosing (Adult):Refractory hypotension (refractory to dopamine/dobutamine): Continuous IV infusion: 1 mcg/min (range: 1-10 mcg/minute) - titrate dosage to desired effect. Usual rate: 1 to 4 mcg/min. Severe cardiac dysfunction may require doses >10 mcg/minute (up to max of 20 mcg/min in a 70kg patient).

Administration: Central line administration only.

Endotracheal: Doses (2-2.5 x IV dose) should be diluted to 10 ml with NS or distilled water prior to administration.

Anaphylaxis (adult): 0.3 mg IM (0.3 ml of a 1:1000 solution). May be repeated if severe anaphylaxis persists - repeat q10 to 15 minutes prn or give 0.1 to 0.25 mg IV (1:10,000) over 5-10min repeat q5 to 15 minutes as needed or start continuous infusion: 1 to 4 mcg/min.

Cardiac arrest: 1 mg IV initially; may be repeated as necessary q 3-5 min

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[TD][h=2]Norepinephrine - LEVOPHED ®[/h]

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[TD]Alpha receptor & Beta-1 agonist. Used to maintain BP in hypotensive states. Most potent vasoconstrictor (Norepi >>> phenylephrine).

Dosage (initial): 8 to 12 mcg/min -titrated to BP (Usual target: SB:80-100 or MAP=80). Usual maintenance: 2 to 4 mcg/min. Note: doses as high as 0.5 to 1.5 mcg/kg/min for 1-10days have been used in septic shock.

Note: Norepinephrine dosage is stated in terms of norepinephrine base and intravenous formulation is norepinephrine bitartrate. Norepinephrine bitartrate 2 mg = Norepinephrine base 1 mg.

Usual range: 8-30 mcg/minute. Range used in clinical trials: 0.01-3 mcg/kg/minute. ACLS dosage range: 0.5 to 30 mcg/minute.

Administer into large vein to avoid the potential for extravasation.

Calculation of drip rate 8 mg/ 250 ml (ml/hr) = mcg/min x 1.875.

Supplied: Injection (soln): 1 mg/ml - 4 ml

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Drug Reference

bamagt · Jan 3, 2012

I think the thing many are forgetting is you may be able to run 1000mcg/min of a certain drug but there comes a point where more isn't necessarily better.

usalsfyre · Jan 3, 2012

Esme, I would hope there's a difference between doing something like giving a med through an A-line (which your not going to find supported in medical literature anywhere) and giving a dose of medication where there's wide variation of the "max". While I can see a firing, a nurse losing her license would be draconian. What makes more sense, going to 42mcg/min to get an acceptable MAP or adding another agent to wean from? This is why in the out-of-hospital word there's been a push away from "protocols and policies" to "guidelines".