Is there a max dose of Levophed?

I just asked this same question last week. There was a pretty big thread on it with lots of great information. In fact it is just a few threads below this one.

We go as high as 100mcg/min, straight drip. This is usually a terminal situation though.

Agree with Mark, we go very high if needed, and this is with other pressors on board too. For the most part tho, it is somewhat futile, and the patient expires despite our intervention.

From the posts I have read there is a wide range that different people/hospitals use. However, I still don't know what the max dose of levophed is, if any? I googled levophed and still have not found a concrete answer to this question. I am gathering that the dose depends on the individual.

I found this info on several websites:

"High Dosage: Great individual variation occurs in the dose required to attain and maintain an adequate blood pressure. In all cases, dosage of Levophed should be titrated according to the response of the patient. Occasionally much larger or even enormous daily doses (as high as 68 mg base or 17 ampuls) may be necessary if the patient remains hypotensive, but occult blood volume depletion should always be suspected and corrected when present. Central venous pressure monitoring is usually helpful in detecting and treating this situation."

That "enourmous daily dose" that was quoted equals to about 47mcg/min. However, I still do not see where there is max dose. However, it does say that that "levophed should be titrated according to the response of the patient".

I suppose to answer your question there is not a true max dose for levo, you do titrate for pt response, as well as add other pressors etc. As far as volume depletion, well that should always be suspected first and fluids should be given before pressor support. As far as CVP monitoring, etc. wellll if you have to give that amount of fluids/colloids, or initiate high dose, or multiple pressor support, a CVP, PA cath etc should be in place.

I think when referring to the 'max' dose of levo.. it's the point when the levo is actually harming the pt.. as opposed to supporting the pt.

I just used levo... at 0.4mcg/kg/min on a pt recently (52cc/hr). The pt weighted roughly 130+ kg.

After the 0.4mcg/kg/min mark.. we would have been shutting down here peripheral vasculature completely.

As someone stated before... after a certain point.. it becomes terminal. You start to see the discoloration of the fingers and toes.. and eventually they begin to mottle.

If you've maxed out on levo and are not in a 'terminal' situation.. you simply need to add other pressor support.

In my case.. we added vasopressin.. and our next option would have been a straight epinephrine drip.

Luckily the pt responded... and 2 days later i was halfed on the levo gtt.. and the vasopressin was off. :)

Our max use to be 30mcg/min, however on your revised sepsis order set it advises to go up to 60mcg/min if needed.

In our facility our max dose for Levophed is 30mcg/min. Just like the other posters have stated once you start to go beyond the max dose it is pointless. I once had a patient on Levo, Neo, Vaso, Epical, and Dopamine and within hours there extremities were modeled all over and expired shortly thereafter.

I think how much levo is used is not as important as how it is used. Back in the day, before Levophed was first line for sepsis, we called it "leave 'em dead" or "dead in the bed" and was a last resort drug. That is because it wasn't used right; the patient would clamp down and die (with a great blood pressure). Now, if the patient is tanked up, I am of the opinion that you should titrate it up until it works. Granted, after about 20 mcg or so, Neo should be added, and Vaso shouldn't be too far behind. But otherwise, used right, and in the right patient (where the cardiogenic effects aren't too harmful)...I've hit 200 mcg with Neo and Vaso on board with a BiCarb gtt and all else. Just be smart about it.

We would go to our sepsis protocol which is 300mcg/min max and Neo we would go to 700mcg. This is only for our really septic shock patients

Generally we need to remember that noradrenaline (or any other trope) is a poor substitute for adequate fluid reses. That said, in the setting of an adequately fluid loaded patient if you've hit 20 mcg/min with no result then you need to add another agent and look at their SVRI to determine what is the cause of the refractory hypotension (pump failure vs actual vascular depletion vs relative vascular depletion [vasoldiation]) If no result with 30 then perhaps some hydrocort plus a second agent, then a third etc.

Been in the goo acouple of times where the clinical picture is muddied to see what we needed to do cia PICCO / SCVO2 /Swann / or some other cardiac measure.

Guess my point is if your current thing ain't working it's time to see if what you were dealing with is what's happening and to add something else.

Cheers.

I was wondering why some of the nurses where whispering "levophed leave em dead"... I had a pt on levophed and I stopped after 30mcg and told the doc that i had max out on levoped, so he added a vasopressin 0.02 then the dude max out on vaspressin.

Back in the day, before Levophed was first line for sepsis, we called it "leave 'em dead" or "dead in the bed" and was a last resort drug. Just be smart about it.