Levophed

Lev·o·phed (lv-fd)

A trademark for a drug preparation of norepinephrine.

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norepinephrine bitartrate Warning - High-alert drug!

Levophed

Pharmacologic class: Sympathomimetic

Therapeutic class: Alpha- and beta-adrenergic agonist, cardiac stimulant, vasopressor

Pregnancy risk category C

FDA Boxed Warning

• If extravasation occurs, infiltrate area promptly with 10 to 15 ml of saline solution containing 5 to 10 mg phentolamine to prevent sloughing and necrosis. Use syringe with fine hypodermic needle, and infiltrate solution liberally throughout area. Give phentolamine as soon as possible; its sympathetic blockade causes immediate local hyperemic changes if area is infiltrated within 12 hours.

Action

Stimulates beta₁ and alpha₁ receptors in sympathetic nervous system, causing vasoconstriction, increased blood pressure, enhanced contractility, and decreased heart rate

Availability

Injection: 1 mg/ml

⊘Indications and dosages

➣ Severe hypotension

Adults: 8 to 12 mcg/minute I.V.; then titrate based on blood pressure response. For maintenance, 2 to 4 mcg/minute.

Contraindications

• Concurrent cyclopropane or halothane anesthesia
• Hypotension caused by blood volume deficit (except in emergencies until blood volume replacement is completed), profound hypoxia or hypercarbia
• Mesenteric or peripheral vascular thrombosis

Precautions

Use cautiously in:
• sulfite sensitivity (some products), especially in asthmatic patients
• arterial embolism, cardiac disease, peripheral vascular disease, hypertension, hyperthyroidism
• patients receiving MAO inhibitors or tricyclic antidepressants concurrently
• elderly patients
• pregnant or breastfeeding patients
• children (safety and efficacy not established).

Administration

• Mix with dextrose 5% in water or dextrose 5% in normal saline solution.
• Inspect solution to make sure it's clear and colorless. Don't infuse if it's brown or pink.
• Administer through infusion pump. Titrate infusion rate to achieve and maintain low-normal systolic blood pressure (80 to 100 mm Hg).
• Continue infusion until adequate blood pressure and tissue perfusion persist without drug therapy.
• Gradually titrate dosage downward.
• To avoid extravasation, administer only into large vein (antecubital) or through central line. Don't use femoral vein in patients who are elderly or have occlusive vascular disorders.
☞ To prevent delivery of large drug concentrations, avoid line stasis and flushing.

Route	Onset	Peak	Duration
I.V.	Immediate	Immediate	1-2 min after infusion ends

Adverse reactions

CNS: headache, anxiety

CV: bradycardia, severe hypertension, arrhythmias

Respiratory: respiratory difficulty

Skin: irritation with extravasation, necrosis

Other: ischemic injury

Interactions

Drug-drug. Alpha-adrenergic blockers: antagonism of norepinephrine effects

Antihistamines, ergot alkaloids, guanethidine, MAO inhibitors, oxytocin, tricyclic antidepressants: severe hypertension

Bretylium, inhalation anesthetics: increased risk of arrhythmias

Patient monitoring

☞ Check blood pressure every 2 minutes until desired pressure is achieved. Recheck every 5 minutes for duration of infusion.
• Maintain continuous ECG monitoring and blood pressure monitoring.
☞ Be aware that headache may signal extreme hypertension and overdose.
• Monitor infusion site for extravasation.
☞ Watch for signs and symptoms of peripheral vascular insufficiency (decreased capillary refill, pale to cyanotic to black skin color).
☞ Never leave patient unattended during infusion.

Patient teaching

• When patient is alert, explain why he's receiving drug.
• Reassure patient he'll be monitored continuously until he's stable.