Max on Levophed?

[Nurse_Sophia]

Hi!

I'm a fairly new ICU RN and recently had a doctor tell me there is no max on Levophed. Our hospital policy states that the recommended max is 40mcg/min. The doctor refused to give me a second pressor because he said that studies have shown there is no difference. I want to research this better but a google search hasn't turned up anything... thoughts?

[RN-LOGIC]

Hey Belgian RN,

I would like to correct some of things said.

you said:

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.

I do agree that vasoconstriction increases preload. However, increasing preload by vasoconstricting its detrimental for the patient. An increase in fluid status increases your END DIASTOLIC VOLUME which increases your stroke volume.

Therefore, your preload increases. However, when you increase your levophed/neo up vasoconstrictions occur thus your afterload increases. This increased afterload increases your END SYSTOLIC VOLUME which may reflect an adequate preload but inadequate or decreased stroke volume.

Also, even though levophed has beta receptors, the alpha receptors take complete control thus the beta receptors do not play a role.

Every septic patient should be on vasopressin regardless.

[Esme12, ASN, BSN, RN]

It still depends .....every practitioner has different theories and allnurses is an international site and we have many international members. Medicine isn't always consistent.

[RN-LOGIC]

It is basic physiology not a theory.

[ICUPrincessNurse]

Our pumps warn us at 100. Hard limit is 150. I've been told I can go as high as 200 but the pump wound't let me. So...150 it is. These are the people who are profoundly septic/bleeding out/actively dying. the last one I had was on the levo, vaso at 0.04, epi at 20 which is our pumps hard max, all to get a MAP around 63. Ended up in SVT so bye bye epi! Also ended up dying, obviously.

[Dodongo, APRN, NP]

Our hospital policy has us max levo at 1mcg/kg/min - which is obviously silly. Epi is supposed to max at .15 mcg/kg/min but we can go as far above that as we need to go. It doesn't make any sense to have a max for a catecholamine. But we do what we're told. Whatever. So we'll have vaso at .04, levo and neo "maxed" and just keep going up on epi until their fingers fall off. A few weeks ago I had a patient on a rotaprone bed, CVVHD, oscillator vent, inhaled nitric oxide, IABP and maxed on all pressors. Her fingers and toes were black, shriveled and hard. So sad. And gross.

[ICUPrincessNurse]

Learned yesterday that max on Neo, per our pumps, is 300 mcg/min.

That patient was fine until we decided to put the chest tube in the empyema... By fine of course, I mean on 120 levo, 120 neo, 100% FiO2, 20 PEEP, sats 92%, PaO2 48, HR 137. You know...fine!! Cytokine release kills!

[OhioCCRN, MSN, NP]

i know this thread is 3 years old but holy crap! a chest tube on 20 of peep? ouch! lung explosion is all i can picture!!

[jamst149]

There is a reason there is a max. Law of diminishing returns. At some point you are just delaying the inevitable. It's futile.