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Levophed Infusion

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Last Updated: 26 October 2020

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General | Latest Info

Administer by Intravenous Infusion. Monitor blood pressure every 23 minutes until it stabilizes and then every 5 minutes. Ecg should be continuously monitor. Do not administer into the veins of legs of elderly patients. Avoid Extravasation. If Extravasation occur, infiltrate the site as soon as possible with 1015 mL of NS containing 510 mg of Phentolamine for adults. Use a syringe with a fine hypodermic needle and liberally infiltrate throughout the ischemic area. Sympathetic blockade with Phentolamine causes immediate and noticeable local hyperemic changes if the area is infiltrated within 12 hours of Extravasation. For prevention of Extravasation, Phentolamine may be added to each 1000 mL of solution containing Norepinephrine. Dilution: concentrate For Injection must be Dilute prior To Administration. Fluids containing Dextrose offer protection against loss of potency due to oxidation; therefore, 5% Dextrose in water or 5% percent Dextrose and Sodium Chloride are generally preferred diluents. Although the manufacturer states that Norepinephrine should not be diluted in normal saline alone, available data supports stability of Norepinephrine in NS at concentrations up to 16 mcg / mL. The manufacturer recommends diluting 4 mg of Norepinephrine in 1000 mL of D5W for a concentration of 4 mcg / mL. However, more commonly used dilution in clinical practice is 4 mg Norepinephrine in 250 mL of D5W Injection For Concentration of 16 mcg / mL. In fluid-restricted patients, concentrations of up to 32 mcg / mL have been used Intravenous Infusion: Infuse IV preferably into antecubital vein of the arm using an infusion pump or other device to control flow rate. Femoral vein may also be used. Do not use catheter tie-in technique because obstruction To blow flow around tubing may lead to stasis and increase local concentration of Norepinephrine. Rate should be titrated according to patient response. Observe IV Infusion site frequently during Administration. If blanching along vein occur, change the infusion site. Care should be taken to avoid Extravasation because Norepinephrine can cause local necrosis.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Warnings

If your doctor has directed you to use this medication for your condition, your doctor or pharmacist may already be aware of any possible drug interactions or side effects and may be monitoring you for them. Do not start, stop, or change dosage of this medicine or any medicine before getting further information from your doctor, healthcare provider or pharmacist first. Isocarboxazid linezolid phenelzine procarbazine selegiline transdermal tranylcypromine norepinephrine has serious interactions with at least 34 different drugs. Norepinephrine has moderate interactions with at least 261 different drugs. Bendroflumethiazide bumetanide chlorothiazide chlorthalidone cyclopenthiazide desmopressin ethacrynic acid eucalyptus furosemide hydrochlorothiazide indapamide methyclothiazide metolazone noni juice sage torsemide in this document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist about all products you use. Keep a list of all your medications with you, and share list with your doctor and pharmacist. Check with your physician if you have health questions or concerns. Aantidote for extravasation ischemia: To prevent sloughing and necrosis in areas where extravasation has taken place, infiltrate areas promptly with 10-15 mL of saline solution containing 5-10 mg of phentolamine mesylate for injection. Use a syringe with a fine hypodermic needle, with solution being infiltrated liberally throughout the area, which is easily identified by its cold, hard, pallid appearance. This medication contains norepinephrine. Do not take Levarterenol or LEVOPHED if you are allergic to norepinephrine or any ingredients contained in this drug. Keep out of reach of children. In case of overdose, get medical help or contact the Poison Control Center immediately.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

DESCRIPTION

Norepinephrine is a sympathomimetic amine which differs from epinephrine by absence of methyl group on nitrogen atom. Norepinephrine Bitartrate is-3 4-dihydroxybenzyl alcohol tartrate monohydrate and has the following structural formula: LEVOPHED is supplied in sterile aqueous solution in form of Bitartrate salt to be administered by intravenous infusion following dilution. Norepinephrine is sparingly soluble in water, very slightly soluble in alcohol and ether, and readily soluble in acids. Each mL contains the equivalent of 1 mg base of norepinephrine, sodium chloride for isotonicity, and not more than 2 mg of sodium metabisulfite as an antioxidant. It has a pH of 3 to 4. 5 air in ampuls has been displaced by nitrogen gas.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

SIDE EFFECTS

The most common adverse effects of norepinephrine relate directly to activation of alpha1 receptors. That is, excessive vasoconstriction can result in decreased end-organ perfusion, which is primarily caused by infusions of norepinephrine without appropriately treating hypovolemia; This can be detrimental as most patients who require infusions of norepinephrine already have poor oxygen delivery or utilization. Vasoconstriction secondary to alpha1 stimulation can result in reflex Bradycardia via baroreceptor reflex, which is generally not compensated for by beta1 activity. The overall result is that cardiac output may decrease, or at most stay the same, despite beta1 agonism. At the same time, increase in systemic vascular resistance increases the work of the heart by increasing afterload, thereby increasing myocardial oxygen demand. Because of these phenomena, benefits of norepinephrine for cardiogenic shock are still unclear but merit consideration under certain conditions. Pulmonary vascular resistance may increase secondary to norepinephrine administration, which could have negative sequelae in patients with pulmonary hypertension. Decrease hepatic blood flow can lead to transient increase in drugs that undergo hepatic metabolism.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

PRECAUTIONS

Whenever possible, infusions of LEVOPHED should be given into large vein, particularly antecubital vein because, when administered into this vein, risk of necrosis of overlying skin from prolonged vasoconstriction is apparently very slight. Some authors have indicated that femoral vein is also an acceptable route of administration. Catheter tie-in techniques should be avoid, if possible, since obstruction of blood flow around tubing may cause stasis and increase local concentration of drug. Occlusive vascular diseases are more likely to occur in lower than in upper extremity. Therefore, one should avoid veins of leg in elderly patients or in those suffering from such disorders. Gangrene has been reported in lower extremity when infusions of LEVOPHED are given in the ankle vein.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Extravasation

By Robin Varela, RN, BSN, content specialist Most nurses are quite familiar with term infiltration when used in conjunction with intravenous therapy,. However, not all nurses are aware of its associated potential for serious complications. The National Database of Nursing Quality Indicators defines IV infiltration as unplanned Administration of medication or nonvesicant solution into surrounding tissue. Iv extravasation is unplanned administration of medication or vesicant solution into surrounding tissue. Fluids and medications that infuse into surrounding tissue can be very damaging and can result in pain and partial to full thickness wounds with tissue necrosis and sloughing. Examples of medications that can cause extravasation include: cytotoxic medications such as certain drugs used in chemotherapy; dyopamine; phenytoin; norepinephrine and phenylephrine. The extent of tissue damage related to extravasation depends on the amount of medication infused and length of time it has infuse. Individuals that are unable to communicate and infants and children are especially at risk. In addition, any patient that is confused or sedate, or has fragile skin or peripheral neuropathy is also at risk. Signs of extravasation include pain, swelling, redness or blistering at the IV site; lack of blood return and an increase in resistance or change in quality of infusion. Treatment for peripheral extravasation is rapid response with the drug phentolamine. Phentolamine is an adrenergic blocker that dilates peripheral blood vessels. To prevent necrosis and sloughing, drug should be diluted with normal saline and injected throughout the area of extravasation. Even when treatment is initiated as soon as possible, injury to surrounding tissues may not be evident for up to four weeks after infiltration has occur. Most importantly, follow your facility policy for extravasation. Perform frequent inspections of your Patients IV site and instruct your patient to alert you if they experience any pain, burning or swelling at the IV insertion site. 2007. Amn Healthcare, Inc. All Rights reserve.


ADRENERGIC RECEPTORS AND VASOPRESSOR PROPERTIES

Vasopressor infiltration leads to high intradermal concentrations of vasopressor into local tissue. As a result, direct adrenergic-mediate vasospasm of smaller veins and vasa vasorum ensues, leading to inadequate distal blood flow. Subsequent increases in hydrostatic pressure of venous circulation cause further effusion of vasopressor into tissues. 9 16 Ischemia then follows parallel to infusion site as vasopressor diffuse into tissue space and tributary veins constrict. As venous inflammation occur, backflow commences into arteriolar capillaries due to hydrostatic pressure. 9 16 Sloughing has also been reported at insertion site of longer peripheral catheters despite maintenance of vein integrity. 16 Risk factors for vasopressor necrosis include presence of vasculopathy, preexisting hypotension, diabetic neuropathy, Raynaud disease, coagulopathy, advanced age, and altered mental status. 10 17 18 Local venous anatomy remains an important variable as well, with higher frequencies of extravasation reported in areas with smaller veins or slower circulation such as antecubital fossa of wrist or saphenous vein of the ankle. 9 10 16 18 Larger veins provide adequate dilution of vasopressor and are less likely to spasm. 9 Although the absolute rate of peripheral vasopressorinduced necrosis is unknown, original rates of ulceration from peripheral administration of norepinephrine were as high as 46-60%. 19 Similarly, infiltration rates as high as 68% have been reported with peripheral administration of dopamine in adults. 20 More recent pediatric literature suggests that rates of infiltration have been reduced to 15% with use of modern venous access devices and larger peripheral veins. 21 Regardless of incidence of extravasation, extended use of vasopressor necessitates eventual placement of central venous access. 22 clinical course of untreated extravasation remains fairly consistent across vasopressors, although it can be difficult to predict whether infiltration will remain asymptomatic or progress to florid necrosis. 10 sites of infiltration typically manifest with blanching, swelling, hypoperfusion, and local hypothermia. This is followed by purple discoloration and extreme pain, and within 48 hours, fluidfilled bullae or vesicle formation. 23 this may lead to skin epithelialization, tissue sloughing, eschar formation, or gangrene. Morbidity from vasopressor necrosis is often high, requiring aggressive tissue debridement, grafting, extremity amputation, or even mortality. Report evidence supporting treatment of extravasation caused by individual vasopressors is outlined in the following section. Most imperative, early treatment can prevent any necrotic complications from occurring. Nondrug therapy has an important role in early management of vasopressor extravasation. Infusions of drug should be stopped immediately, with attempts to remove as much of the infiltrated drug as possible from the catheter. Limb should be elevate, with application of heat proximal to cannulation site, which may assist in further vasodilation. 9 Cooling areas should be avoided because it may cause exacerbation of vasoconstrictive effects of vasopressor.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

CONTRAINDICATIONS

There are no absolute contraindications to administration of norepinephrine. As mentioned above, norepinephrine use may be contraindicate to treating hypotension that is likely secondary to cardiogenic mechanisms. Additionally, for hypotension primarily related to hypovolemia, norepinephrine is probably not the best agent. The Fda does state that its use could be consideration in low volume states, but only as an emergency measure for maintaining coronary or cerebral perfusion pressure while waiting for appropriate volume resuscitation. Generally, use of norepinephrine should be avoided in patients with mesenteric or peripheral vascular thrombosis as subsequent vasoconstriction will increase area of ischemia and infarction. Profound hypoxia or hypercarbia can sensitize the myocardium to unstable arrhythmias, which could be exacerbated or even be initiated by use of norepinephrine-this is also the case with specific anesthetic agents, such as halothane and cyclopropane. Levophed, preparation of norepinephrine, typically used in clinical setting, contains sodium metabisulfite, which may cause allergic reactions in susceptible individuals. This effect may be more common in asthmatics. Care is necessary when using norepinephrine concomitantly with monoamine oxidase inhibitors or amitriptyline and imipramine-type antidepressants. The combination of any of these drugs can lead to severe, prolonged hypertension.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Introduction

Vasoactive medications are indicated when Systolic Blood Pressure has decreased to > 30mmHg from baseline or Mean Arteriole Pressure less than 60-65mmHg and when either condition results in end-organ dysfunction due to hypoperfusion. Additionally, Vasoactive medications are used for management of hypertensive crisis, flash pulmonary edema, sepsis, shock states, atrial fibrillation with rapid ventricular response, supraventricular tachycardia, heart failure, and hemodynamically unstable patients. Vasopressors should be infused via central access but can be administered peripherally until central access is obtain. All Vasoactive drips can cause severe tissue injury if infiltration occur. It should also be considered to have arterial line pressure monitoring for patients on Vasoactive drips. A Physician's order is needed to administer any Vasoactive drip, and the order should include parameters for titrate relating to heart rate, blood pressure, respiratory rate, and oxygen saturation if indicate. Healthcare providers must know maximum dose, minimum dose, titration parameters, and side effects for all critical care drips and infusions. Remember that cardiac output is the holy grail of hemodynamics. To maintain blood pressure and heart rate, cardiac output must be sustain. Cardiac output is defined by stroke volume times heart rate. Cardiac output is a vital part of oxygen delivery, blood pressure, urine output, and perfusion. There are many drugs used for hemodynamic instability, cardiogenic shock, and neurogenic shock. Norepinephrine, epinephrine, phenylephrine, vasopressin, dopamine, and dobutamine are a few of the medications used. Volume loss and hypovolemia should be corrected before administration of any vasopressor. If fluid status is unknown, then continue close hemodynamic monitoring to determine the efficacy of Vasoactive drip. 1 Vasoactive drips will only temporarily correct hypovolemia, and then the patient will become unstable again until the fluid volume status of the patient is correct. All critical care drips must be on infusion pump. All patients on Vasoactive medications must be on continuous heart monitor, along with blood pressure and oxygen saturation monitoring. Emergency resuscitative equipment and medications should always be immediately available to manage any unwanted medication reactions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Pre-Mixed Dopamine

Table

Cat. No.Size
D1442-60SS250 mL
D1482-60SS250 mL

Do not add any alkalinizing substance since Dopamine is inactivated in alkaline solution. Patients who have been treated with monoamine oxidase inhibitors prior to ADMINISTRATION of Dopamine will require substantially reduced DOSAGE. See Drug Interactions below. This product contains sodium metabisulfite, sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown and probably low. Sulfite sensitivity is: seen more frequently in asthmatics than in nonasthmatic people. Evidence is inadequate for fully defining proper DOSAGE and limitations for use in children. Solutions containing Dextrose without electrolytes should not be administered simultaneously with blood through the same infusion set because of the possibility of agglomeration of erythrocytes. Administration of intravenous solutions can cause fluid and / or solute overload resulting in dilution of serum electrolyte concentrations, overhydration, congest states or pulmonary edema. Excess ADMINISTRATION of potassium-free solutions may result in significant hypokalemia. Because dosages of this drug are titrated to response, no additives should be mixed with Dopamine Hydrochloride in 5% Dextrose Injection USP.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

The formulas of the active ingredients are:

IngredientsMolecular FormulaMolecular Weight
Hydrous Dextrose USP198.17
Dopamine Hydrochloride189.64
* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Epinephrine

Aantidote for extravasation ischemia: To prevent sloughing and necrosis in areas where extravasation has taken place, infiltrate areas promptly with 10-15 mL of saline solution containing 5-10 mg of phentolamine mesylate for injection. Use a syringe with a fine hypodermic needle, with solution being infiltrated liberally throughout the area, which is easily identified by its cold, hard, pallid appearance. This medication contains norepinephrine. Do not take Levarterenol or Levophed if you are allergic to norepinephrine or any ingredients contained in this drug. Keep out of reach of children. In case of overdose, get medical help or contact the Poison Control Center immediately.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

Sources

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions.

* Please keep in mind that all text is machine-generated, we do not bear any responsibility, and you should always get advice from professionals before taking any actions

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