Question about gtt titration

Usually the neighborhood of 30mcg is the upper limit. If you get that high, watch for tissue necrosis in the extremeites -- you can be they aren't being perfused!

Why not Matt? What's going on with the med that the ext. aren't being perfused?

It's the nature of how the medication works...by clamping down on the capillary bed = decrease tissue perfusion

Levophed (norepinephrine) is a pure (well, almost pure) alpha-adrenergic agonist -- that is, its primary function is to constrict the peripheral arterial system. (It has some minor beta effects as well.) Put another way, Levo increases blood pressure by increasing afterload.

With high doses of Levo, the arterioles are constricted to the point where they do not perfuse.

Never, never, confuse blood pressure with perfusion! While in most cases the one correlates with the other, in others, such as high alpha stimulation, blood pressure might be working against perfusion. It's a lot like putting your thumb over the end of a garden hose: the pressure might have been increased, but the flow has been decreased.

This all is one reason I prefer SVO2 monitoring to measure perfusion, rather than BP.... but that's another thread.

A doc I worked with used to order the Levo be mixed with a small amount of Regitine--claimed it was capillary-sparing. It seemed to make the Levo a little less ugly, anyway.

Levophed...leave 'em dead. In the CT ICU where I used to work, levophed was a last resort drug, but I have seen it used more commonly than neosynephrine, which we used more extensively in leui of levophed.

I have seen levophed given at doses to infinity. Open up the drip and let it run in before the final code is called type thing. I prefer neo myself. In my humble opinion, levo is best used if there is concurrent heart block and no pacer in place yet.

LOVE neo. We used to use it a lot more than Lethalphed.

I agree... Neo is a wonderful drug. I have found Levo to be more effective in cases of really bad sepsis, though.

Neo's nice... about as pure alpha as you can get.

In our unit, we almost alway use levophed...have only seen neo used once. I don't know if the docs just don't like it or what. Anyway, I had a patient this summer with levo running at 70 mcgs. It was absolutely ridiculous.

I have seen infusions for norepi calculated 2 ways...

The "standard" approach which is up to 30mcg/minute.

The "weight based" approach which is 0.1-0.2mcg/kg/minute.

For weight based, lets say 100kg person (average in Indiana) at 0.2mcg/kg/minute. That figures out to only 20mcg/minute, below the high limit for "standard" infusion.

I have seen higher doses given in severe sepsis and guess what? They all died! Norepi, sepsis, both, who knows?