Levophed vs. Neo

[hell000nurse]

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 :)

[damanRN]

Apparently you cannot read. I even posted the web link. Levo requires a central line. Also where do you people work at that you give vasoconstictors without central lines? In the er while waiting for a line maybe, but not on a unit. I have not worked in a unit where we put any vasoconstricter without a central line for at least five years. Think about it. If its not going in (extravasating) whats it doing for you patients blood pressure. That sad nonsense about your wife going to die but we can't use a vasoconstrictor peripherally is nonsense. The first thing your going to do is a fluid challenge and while that is going on you get a central line placed.

why would it say infuse into large vein if it can only be given in central line? are people putting central lines into small veins? The websit YOU sited states

"Administration: I.V.

Administer into large vein to avoid the potential for extravasation; potent drug, must be diluted prior to use; do not administer NaHCO3 through an I.V. line containing norepinephrine. Central line administration is required. " The central line is required statement is r/t the NaHCO3 and levophed combo. it goes on to say

"Administration: I.V. Detail

Administer into large vein to avoid the potential for extravasation." The ac is a large vein.

Up to date removes the ambiguity of the merk info. look up levophed on up to date you'll find this:

"Administration

Administer into large vein to avoid the potential for extravasation; potent drug, must be diluted prior to use; do not administer NaHCO3 through an I.V. line containing norepinephrine." same exact thing without the central line confusion.

[Lucyinthesky]

Apparently you cannot read. I even posted the web link. Levo requires a central line. Also where do you people work at that you give vasoconstictors without central lines? In the er while waiting for a line maybe, but not on a unit. I have not worked in a unit where we put any vasoconstricter without a central line for at least five years. Think about it. If its not going in (extravasating) whats it doing for you patients blood pressure. That sad nonsense about your wife going to die but we can't use a vasoconstrictor peripherally is nonsense. The first thing your going to do is a fluid challenge and while that is going on you get a central line placed.

I think it is agreed by all that the BEST route is via a central line but this is not immediately possible in all hospitals. While you are awaiting your central line Levophed may be necessary in a WORKING peripheral vein. If it was extravasating as stated above you wouldn't be giving ANYTHING through that vein let alone levophed. If it is a critical situation you don't have time to wait for a central line to be put in and need to work with what you have on hand to stabilize the patient.

[meandragonbrett]

Also where do you people work at that you give vasoconstictors without central lines? In the er while waiting for a line maybe, but not on a unit. I have not worked in a unit where we put any vasoconstricter without a central line for at least five years.

Not everybody works in the type of facility where you work. Some of us work in non-teaching private hospitals where there is nobody in house at night and you're told to deal with what you have. In a perfect world, a CVL would be admission criteria for the unit.

Lots of facilities run pressors in a PIV on a routine basis...especially in the middle of the night. Kinda hard to place a CVL when you have a pressure in the 40' and 50's anyways.

[teraiko]

i work in a smaller non-teaching hospital where it can be difficult if not impossible to have a central line placed on an overnight shift. so i wanted to validate what you were saying. we can usually get someone (whether they're on the case or not) to place one on 'humanitarian' grounds even if the doc's on the case won't come in. but, that still often takes more than half a shift. that means we've run high doses of neo/levo/dopa peripherally until we can make that happen. (life over limb.) we've even had to get the house supervisor to call the chief medical officer of the hospital at home in the middle of the night to force an md to come in and place a line. (yes, it can be that bad.)

i just want people who haven't been in that situation to realize how hard it can be to get a line placed. we all agree it's better to have a line.

back to the original question. anecdotally, i can tell you a few things from my personal experience. take this free info for what it's worth, my opinion only.

dopamine is the old stand by. it works for most things and has been used forever. levophed is harsh on body organs but works when nothing else will. (it is harder on organs though because it strongly vasoconstricts all vessels, not just the periphery.) neosynephrine is much better for patients who need pressors but have low ejection fractions or myocardial dysfunction of some sort (e.g., cardiomyopathy or recent cardiac insult). levophed can push those guys toward cardiogenic problems and make shock worse. in all patient's, dopamine causes tachycardia more often. in metabolic acidosis dopamine seems to cause more ectopy versus other pressors. neosynephrine isn't always enough. i'm sure there are other oppinions and experience, but that's mine.

[NtannRN]

I guess I apparently CAN read since there is more than 1 person to stand by the fact that yes you do indeed infuse levo and neo peripherally if need be. There was no need for the rudness, I was at first on the side of central line only, which changed when bending the ears of my senior more seasoned nurses.

[lakemurray]

First I apologize especially to Ntannrn. I was rude. I did not to be intimidating anyone and am sorry if I did. Down the page on the site I posted it does state for central line use only but then also says to give through a large vein. Ambiguity is not nice. The hosp I work in has about 150 beds. We have two full time picc nurses and get central lines from residents/attendings very quickly. I had to ask around when the last time a pressor was given without a line, a couple of years ago a resident wanted to run dopamine and the rn refused to do it without a line, the short story is that the patient got the line and we get them very fast now (the patient was ok). I realize that what is done is not always what should be done and you do the best you can with what you have. For those of you who do not get lines maybe you should start an initiative at your hosp. to get more of them. We get them because they are cost effective. I originally was attracted to this thread because because we are taking lidocaine off our crash carts and one of my managers asked me if I thought levo would be a good replacement. I told her no because I was sure someone would try and start it up before their was a line in place. We do not keep levo on the crash carts. I am sorry if I took this thread away from the original subject. I won't talk about the line thing anymore. As I recall about three or four years ago there was a good article on sepsis in the critical care journal and I think it explained the use of levophed.

[APNgonnabe]

I originally was attracted to this thread because because we are taking lidocaine off our crash carts and one of my managers asked me if I thought levo would be a good replacement. I told her no because I was sure someone would try and start it up before their was a line in place.

I'm hoping that there was a typo or something that I missed because a manager asking if levophed to replace lidocaine...um wow.

[PMFB-RN, RN]

I work in a small community hospital ICU. We run pressors peripherally ALL the time. We try to push for a central line but this is a VERY Doctor oriented hospital and are often ignored. LIke the PP said, you do with what you have in the best interest of the patient.

*** Where I work I can place a mid line PIC without orders per policy and will do so if I need to run a vaso active in a patient who does not have a central line. Usually our patients have central lines but sometimes, like if they where crashing up on the floor and they are transfered to the ICU they may not.

If I was in your position of caring for a patient who clearly needed a central line and your docs refused to place one I would start educating the patient's family about the risks you are running. If they ask why we are not giving the drug through a central line I will tell them "the doctor has decided not to place one, I don't know why" and let them ask the doctor why he has chosen not to place a central line and is putting their family member at risk.

[APNgonnabe]

Agreed that a Midline is probably better than a standard peripheral but I am under the impression that mid lines are not central

[PMFB-RN, RN]

Agreed that a Midline is probably better than a standard peripheral but I am under the impression that mid lines are not central

*** No they are not but per our facility policy we can run vaso actives through them. We do not have a policy that allows us to run vaso active through peripherals, though in some emergencies we will do so. Even though we are a large hospital and the only tertiary care hospital for a huge geographical area we do not have physicians in our ICU except when they round in the morning. We have a resident or attending on call but they are also on call to do surgery, or sometimes they go home and take call from there.

During the week on day shift we have a wonderful PA who will place any lines that are needed. The rest of the time it's either a PICC nurse or the on call resident if they are available and sometimes they are not.

My main point was that if a patient needed a central line and the physician simlpy decided not and was blowing me off to I would educate the family about the drug we are giving and how we are giving it and explain what the risks are compaired to running in a central line.

I would aslo document that I suggested a central line to the physician.

[marty6001, EdD, EMT-P, APRN]

Here's the difference as I see it... Neo is pure alpha effect. Therefore it is used for vessel constriction and can quickly damage the kidneys,etc.. I typically use Neo for short term hypotension post-op or hypovolemic shock. Levo has some alpha and some beta effect, therefore less damage as it also is causing increased contractility as well as vessel constriction. For me, Levo is drug of choice in septic shock and even in cardiogenic shock in some cases.

[diosadelsol, ADN, BSN, MSN, RN, APRN, CRNA]

Neo you can use peripherally, levo is always on a central line of some sort.

While it isn't ideal, Levo can be run peripherally. We have to do it a lot in my dinky ICU.