Titrating Levophed

[saz]

Nanograms vs mg/ml? What are the major differences? What would be the conversion between the two? How high can you go when titrating mcg/kg/min before you want to start thinking about other options?

Thank you.

[Corey Narry, MSN, RN, NP]

There will be some institutional variations with this question.  You should consult with your intensivists as well as any policies that your hospital's Pharmacology and Therapeutics Committee recommends.  In our institution, the MICU's, Neuro ICU's, and SICU's dose norepinephrine in mcg/min.  The Epic order that I would write gives a range of 0-20 mcg/min which was agreed upon as the de facto range for our hospital though we've gone up higher than 20 but at that point we start looking for another vasopressor to add.  In the Cardiac ICU's the dosing is mcg/kg/min and the range per the Epic order is 0-0.2 mcg/kg/min.  In the Cardiac Surgery population, we've used higher doses than 0.2 mcg/kg/min.  The weight based dosing is more accurate.

[JBMmom, MSN, NP]

My hospital also uses non-weight based dosing for levophed. Our standard order was 2-30 mcg/min until recently when our health system went to 0-60 mcg/min. As juan pointed out, we also look for adding other pressors before reaching anywhere near max. I'll ask for vasopressin when we hit 10-12 mcg/min and then if we're still getting up into the 30-40 mcg/min range I'll ask about adding another pressor- usually neo or epinephrine, neo more often if the patient is tachycardic and epi might be ordered when we anticipate a patient may code, to reduce the interventions required during the code. Of course if the hypotension is cardiogenic shock related rather than septic shock, maybe we're looking at adding a dobutamine drip instead of straight pressors. 

[LovingLife123]

We do mcg/kg/min and our max is .5.  But, if I was hitting .4 or .45 and staying there for a long time and only getting a MAP of 60-65 I’d start asking for Vaso.  

[Nurse Pompom]

On 1/21/2021 at 12:09 PM, saz said:

Nanograms vs mg/ml? What are the major differences? What would be the conversion between the two? How high can you go when titrating mcg/kg/min before you want to start thinking about other options?

Thank you.

You should have parameters in your emar for titration? If you don't, they have to add them to your order, how else you're going to know what to do? Usually it's about keeping the map >65. However I have seen higher or lower MAP required. That's why it should be in your order. Usually other option is the addition of another pressor.