[cardiacRN2006]

Originally Posted by diarygirl512

I think I have seen necrosis more in septic patients - probably partially due to the DIC-like effect of all the microemboli...

Me too. I have seen it tons of times in DIC, but never r/t levo...

[cvicurn88]

Have you ever heard the saying, "levophed, leave them dead." I know it sounds harsh. The reason for this saying is because of the degree of constriction levophed causes to maintain blood pressure. It increases the svr so dramatically to ensure the blood is perfusing the heart/brain/etc. The first things that show the effect of this "clamping down" are the fingers, toes, earlobes. I have even seen the tip of a nose become cyanotic due to levophed. The pt. is obviously very sick if he/she requires high doses of levphed and may also be on other pressors such as neo, vasopressin or epi gtts. It is not unusual for a pt. that requires high doses of levophed to have necrotic digits, thus amputations.

[Christie RN2006]

I have seen my share of mottling, necrosis and cold extremities due to pressors. If they are to the point that they need pressors that badly just to survive, they had better be willing to sacrifice a few toes. I have only seen one case get bad enough that the person actually lost toes, they ended up dying from their illnesses.

If the toes are bad enough that they are beyond repair, we will amputate.

[ManNurse96]

We have a patient on 7 mcg/min (relatively low dose) of levophed right now and he is developing digital necrosis on both feet. It is the price that is paid. I have seen necrosis many times from levo. Sometimes we've put ntg paste on the digits, but it rarely does anything.

[sharrie]

We used to use phenoxibenzamine in conjunction with nor-adrenaline but still used to get necrosis.

Sometimes you just need to accept it is the lesser of the 2 evils

[janfrn]

We see it occasionally in our PICU, usually from higher-than-recommended doses in septic kids. We call it "nor-epi toe"; some end up with amputations, but when we use nitropaste and a transparent dressing BID as we did recently with a tiny gal on ECLS for severe adenovirus, we are usually able to salvage the digit. The worst I've seen was a teenager who had an above-the-ankle amputation, but her necrosis was from a combination of factors: high-dose pressors, ECLS cannulation in her left femorals, DIC... and probably other factors as well. She's now 20 years old, cognitively normal but physically devastated, and she lives at home.

[TopherSRN]

If they are on high enough doses of pressors to develop mottled/hypoperfused extremities the odds of them walking out of the hospital are slim; so they don't need the toes/extremeities anyway.


The whole levophed - leave em dead philosophy has fallen out of vogue(levo is now the first line pressor for sepsis) so I would hesitate to perpetuate that kind of thinking. Some ignorant people still spout that mantra anytime someone mentions levo.

I've never seen even marked mottling of extremeities on < .15 m/k/m of Epi or Levo. The patients I've seen it on are on .2-.3 of both epi and levo + dopa and/or vasopressin. Hypoperfusion of the extremities is just part of the game at those doses. I hope someone doesn't page a physician in the middle of the night to inform them of this (when on high dose pressors), lol.

[pebbles]

..not to mention it the pt is sick enough to be on high dose of ANY pressors, esp norepi for long enough to cause necrotic feet - they have bigger problems. They also have limited resources within their body to preserve their own tissues at the level of the feet.

Most of the pt's I've seen with that level of necrosis do end up with amputations (if they survive). Bu if it's a choice between "maybe" losing your foot, or dying for sure, I guess that really isn't a choice.

[lorilou22RN]

Levo, shmevo, cut it off. Am I totally jaded. If the patient is maxed on Levo, and other pressors, perhaps it is time for a Celestial Transfer?

[got2luvnights]

Levophed is a very potent pressor that literature supports to be the drug of choice in a septic patient. It is critical that you know that your pt's hypotension is not the result of hypovolemia. Trying to clamp down on a dry pt is a recipe for a disaster including risking digits. A swan ganz catheter or a least a CVP can help one gauge this. I also agree that necrotic digits are often dealt with by amputation. Hopes this helps.