Levophed vs. Neo

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    Hey all - wondering about how many of your facilities use levophed as 1st line defense for hypotension versus neosynephrine. I'm actually wondering why my MICU docs don't use neo more. I know that in general, levo is a go-to 1st ... but when you think of your septic patient who is already tachycardic from their fever, and hypotensive....why not go with the neo that will help increase the BP and decrease the HR?

    thoughts/feelings? discuss
  2. 48 Comments so far...

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    Just a thought, but with the negative chronotropic effects, would you run the risk of inducing further hypotension?
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    Quote from WolfpackRed
    Just a thought, but with the negative chronotropic effects, would you run the risk of inducing further hypotension?
    i suppose its possible but i dont think its going to cause THAT significant of a drop in HR as to cause a subsequent drop in blood pressure? i really dont know. i guess that goes back to my original question...maybe there is some specific reason that im not aware of as to why they dont use neo more often
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    When I worked the ICU we used Levophed as our first line in the septic patient along with boluses of Albumin. Neosynephrine was usually used as a second line agent. Remeber levophed works on beta and alpha receptors. Actually it only mildly stimulates beta receptors. It stimulates alpha receptors much more. Neo on the other hand is a purely alpha-agonist drug. This is my opinion clinically levophed was much more potent than neo. I always though neo was a rather weak vasopressor. Actually in one of the doc's pharm book I was looking stated that neo should be used first then levo, because levo was deemed more potent. Epical and vasopressin are good vasopressor too.
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    Quote from ibnathan
    When I worked the ICU we used Levophed as our first line in the septic patient along with boluses of Albumin. Neosynephrine was usually used as a second line agent. Remeber levophed works on beta and alpha receptors. Actually it only mildly stimulates beta receptors. It stimulates alpha receptors much more. Neo on the other hand is a purely alpha-agonist drug. This is my opinion clinically levophed was much more potent than neo. I always though neo was a rather weak vasopressor. Actually in one of the doc's pharm book I was looking stated that neo should be used first then levo, because levo was deemed more potent. Epical and vasopressin are good vasopressor too.
    epical?

    levo is alpha with a little beta, yes...but it does cause an increase in myocardial o2 consumption....and not to mention what it can do to your poor limbs at high doses.

    so, if neo is a PURE alpha agonist, why not use that instead for BP control?
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    Quote from ibnathan
    I always though neo was a rather weak vasopressor. Actually in one of the doc's pharm book I was looking stated that neo should be used first then levo, because levo was deemed more potent. Epical and vasopressin are good vasopressor too.
    You would be correct. Neo is the first-choice.. first-line defense of low BP. Levo on the other hand used to be considered your 'last' defense. Meaning that if the pt needed levo.. the outlook was not good.
    The current thinking is to eliminate the middle man (neo).. and give the pt the strongest support possible as soon as possible.
    On our Surgical/Trauma ICU we go right to Levo. The only time I even see neo.. is when they are returning from the OR.. and anesthesia used it during the OR.
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    Back in the day, you could tell where a doc did residency based on which vasopressor they prefered: Epi = West Coast, Levo = East Coast, Dopa = Midwest.

    With the introduction of phenylephrine (Neo) and mobility, things have gotten a bit hazy.

    Generally, the line of thinking I hear is go with the biggest guns first. Then, once things have smoothed out and if it's possible, chqange to Neo. The only docs these days that I see going with Neo first are my cardiac surgeons (slightly less cardiac whip), and my trauma surgeons when they are concerned about peripheral perfusion (cursh injuries, amputations, etc.). Actually, the cardiac cutters are also worried about peripheral perfusion and donor site healing, too.
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    For septic pts, we go straight to Levo first. Then Neo and then Vasopressin if needed. And if things really get ugly then we start on Epi.
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    Epical is usually used by our cardiac surgeons after a cabg. The mixture is 2 grams of Epi and 2 to 4 grams of calcium chloride. Vasopressin is a good drug to use as well. Generally once you hit two vasopressor your prognosis is poor.
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    Quote from ibnathan
    Epical is usually used by our cardiac surgeons after a cabg. The mixture is 2 grams of Epi and 2 to 4 grams of calcium chloride. Vasopressin is a good drug to use as well. Generally once you hit two vasopressor your prognosis is poor.
    I've never heard of such a thing... what is the actual constitution of the mixture (2-4g in how much fluid? at what rate is it given?) and what is the rationale for its use?


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