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Levophed Infusion Rate

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Last Updated: 21 October 2020

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General Administration Information For storage Information, see Specific product Information within How Supplied section. Route - Specific Administration Injectable Administration - Visually inspect parenteral products for particulate matter and discoloration prior to Administration whenever solution and container permit. - Do not use solution if its color is pinkish or darker than slightly yellow or if it contains precipitate. Intravenous Administration - Address hypovolemia before initiation of Norepinephrine Therapy. - Administer whole blood or plasma, if indicated to increase blood volume, separately. - Norepinephrine is inactivated in alkaline solutions; do not mix with bicarbonate. Dilution - Dilute Norepinephrine 4 mg in 1 000 mL of 5% Dextrose Injection, 0. 9% Sodium Chloride Injection, or 5% Dextrose and 0. 9% Sodium Chloride Injection For Concentration of 4 mcg / mL. - Dextrose - containing fluids offer protection against loss of potency due to oxidation; therefore, 5% Dextrose Injection or 5% Dextrose and 0. A 9% Sodium Chloride Injection is generally the preferred diluents. Although FDA - approved labeling States that dilution of Norepinephrine is 0. 9% Sodium Chloride Injection alone is not recommend, data support stability of Norepinephrine at 0. 9% Sodium Chloride Injection at concentrations up to 16 mcg / mL. - Ismp recommends Standard Concentration For Neonatal Infusions: 16 mcg / mL - single Children's medical center reports use of Standard Norepinephrine concentrations of 8 mcg / mL and 64 mcg / mL for Infusions via smart - pumps. - Concentration of 100 mcg / mL in 5% Dextrose Injection was used in a small study of Neonates with hypotension due to septic shock refractory To fluid resuscitation and dopamine or dobutamine Infusion. Central catheters were used for Infusion. - Storage: Stable For up To 7 days at room temperature in 5% Dextrose Injection or 0. 9% Sodium Chloride Injection at concentrations of 4 mcg / mL or 16 mcg / mL. Continuous IV Infusion - May administered initially via peripheral IV and changed to central line Administration as soon as possible. Infuse into a large vein. Avoid Infusions into the veins of legs in patients with occlusive vascular disease of legs. - Avoid using catheter - tie - in technique. - Monitor Blood Pressure every 2 minutes until the desired hemodynamic effect is achieve, then monitor blood pressure every 5 minutes for the duration of the Infusion. - Check Infusion site frequently for free flow, and monitor for signs of Extravasation. - When discontinuing Infusion, reduce flow rate gradually. Avoid abrupt withdrawal. Extravasation Management - Extravasation Management instructions are provided in FDA - approved labeling; instructions are not specific to pediatric patients and may require adjustments for some patients. - To prevent sloughing and necrosis in areas in which Extravasation has occur, infiltrate ischemic area as soon as possible, using a syringe with fine hypodermic needle with Phentolamine 5 to 10 mg in 10 to 15 mL of 0. 9% Sodium Chloride Injection. - Sympathetic blockade with Phentolamine causes immediate and conspicuous local hyperemic changes if the area is infiltrated within 12 hours. Nervous system adverse effects that can occur with Norepinephrine use include anxiety and headache. Hypertension and bradycardia are the most common adverse reactions associated with Norepinephrine. Norepinephrine increases intracellular calcium concentrations and may cause arrhythmias, particularly in the setting of hypoxemia or hypercarbia.

* 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

Caution should be observed to avoid EXTRAVASATION of norepinephrine during intravenous administration. Check infusion sites frequently FOR free - flow. Peripheral vasoconstriction or ISCHEMIA, tissue necrosis, and / or gangrene in the surrounding area can occur following EXTRAVASATION. Blanching along the course of infused vein, sometimes without obvious EXTRAVASATION, has been attributed to vasa vasorum constriction with increased permeability of vein wall, permitting some leakage. This also may progress on rare occasions to superficial slough, particularly during infusion into leg veins in geriatric patients or in those suffering from obliterative peripheral vascular disease. Hence, if blanching occurs, consideration should be given to the advisability of changing infusion site at intervals to allow the effects of local vasoconstriction to subside. If EXTRAVASATION occur, affected area should be infiltrated as soon as possible, To prevent necrosis, using normal saline solution containing phentolamine, injected liberally throughout Ischemic area using a fine hypodermic needle. Ischemic areas may be identified by their cool, hard, and pallid appearance. Sympathetic blockade with phentolamine causes immediate and noticeable local hyperemic changes if the area is infiltrated within 12 hours of EXTRAVASATION. Phentolamine ANTIDOTE should be given as soon as possible after EXTRAVASATION is observe.

* 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

Body As Whole: Ischemic injury due to potent vasoconstrictor action and tissue hypoxia. Cardiovascular System: Bradycardia, probably as reflex result of rise in Blood Pressure, arrhythmias. Prolonged administration of any potent vasopressor may result in plasma volume depletion which should be continuously corrected by appropriate fluid and electrolyte replacement therapy. If plasma volumes are not correct, hypotension may recur when LEVOPHED is discontinue, or Blood Pressure may be maintained at risk of severe peripheral and visceral vasoconstriction with diminution in blood flow and tissue perfusion with subsequent tissue hypoxia and lactic acidosis and possible Ischemic injury. Gangrene of extremities has been rarely report. Overdoses or conventional doses in hypersensitive persons cause severe hypertension with violent headache, photophobia, stabbing retrosternal pain, pallor, intense sweating, and vomiting.


DOSAGE AND ADMINISTRATION

Because of its relatively short half - life of 2. 5 minutes, typically, administration of norepinephrine is by continuous infusion. Fda recommends diluting of concentrated norepinephrine in dextrose - containing solutions before infusion, providing protection against potential oxidation and subsequent loss of drug potency. Fda recommends explicitly against using saline as sole diluent. Common technique is to start infusion at 8 mcg to 12 mcg per minute and titrate to desired pressure. The average maintenance dose is around 2 to 4 mcg per minute. If possible, infusions of norepinephrine should use tubing separate from blood products. It is highly recommended to infuse norepinephrine through large - bore peripheral intravenous catheters or central venous catheters. Ideally, peripheral infusion should be in upper extremity, preferably through antecubital vein, as this provides the least risk of ischemia secondary to extravasation. Lower extremity veins should be avoided if at all possible as occlusive vascular diseases are more likely to occur in lower extremities. Extravasation into local tissue can cause significant ischemia and subsequent necrosis. Should extravasation be suspect, infusion should stop immediately. Attempts should be made to remove any injected medication. If continuing infusion is necessary, it should be restart at a different site, ideally in different extremity. Local areas should then be infiltrated with phentolamine. It is worth noting that hypotension secondary to hypovolemia should have treatment with fluid resuscitation as priority. Using vasopressors such as norepinephrine in patients who have not had appropriate resuscitation may result in worsening ischemia and an overall decline in clinical status.

* 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

Dobutamine

Clinical experience with Dobutamine following Myocardial Infarction has been insufficient to establish the safety of the drug for this use; there is concern that any agent that increases contractile force and heart rate may increase the size of Infarction by intensifying ischemia, but we do not know whether Dobutamine does so may cause marked increase in heart rate or blood pressure, especially systolic pressure; because Dobutamine facilitates atrioventricular conduction, patients with atrial fibrillation are at risk of developing rapid ventricular response; in patients who have atrial fibrillation with rapid ventricular response, digitalis preparation should be use prior to institution of therapy with Dobutamine; patients with pre - existing hypertension appear to face increase risk of developing exaggerated pressure response during administration of Dobutamine, monitor blood pressure continuously; pulmonary wedge pressure and cardiac output should be monitor whenever possible to aid safe and effective infusion of Dobutamine in 5% dextrose Injection, USP Dobutamine may cause marked increase in heart rate or blood pressure, especially systolic pressure. Approximately 10% of patients in clinical studies have had rate increases of 30 beats / minute or more, and about 7. 5% have had 50 mm Hg or greater increase in systolic pressure. Usually, reduction of dosage promptly reverses these effects. Because Dobutamine facilitates atrioventricular conduction, patients with atrial fibrillation are at risk of developing rapid ventricular response. Patients with preexisting hypertension appear to face increased risk of developing exaggerated pressure response. Dobutamine may precipitate or exacerbate ventricular ectopic activity, but it rarely causes ventricular tachycardia. Reactions suggestive of hypersensitivity associated with administration of Dobutamine Injection, including skin rash, fever, eosinophilia, and bronchospasm, have been reported occasionally. Dobutamine Injection 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.

* 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 / PRECAUTIONS

Levophed should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be complete. If LEVOPHED is continuously administered to maintain blood pressure in the absence of blood volume replacement, following may occur: severe peripheral and visceral vasoconstriction, decreased renal perfusion and urine output, poor systemic blood flow despite normal blood pressure, tissue hypoxia, and lactate acidosis. Levophed should also not be given to patients with mesenteric or peripheral vascular thrombosis unless, in the opinion of the attending physician, administration of LEVOPHED is necessary as a life - saving procedure. Cyclopropane and halothane anesthetics increase cardiac autonomic irritability and therefore seem to sensitize the myocardium to action of intravenously administered epinephrine or norepinephrine. Hence, use of LEVOPHED during cyclopropane and halothane anesthesia is generally considered contraindicate because of the risk of producing ventricular tachycardia or fibrillation. The same type of cardiac arrhythmias may result from use of LEVOPHED in patients with profound hypoxia or hypercarbia.

* 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

PREGNANCY AND LACTATION

Background and Goal of Study: There are no human studies with norepinephrine in pregnancy, and it is indicated only if risk to maternal survival outweighs potential harm to the fetus. Materials and Methods: 28 yr female presented To ER with worsening chest pain and shortness of breath 2 years after undergoing AVR with mechanical valve. Tte shows thrombosis of prosthetic valve with LV distension. Ultrasound show active fetus with good beat - To - beat variability at 140 - 150. The patient was rushed emergently to or to redo AVR using CPB. Bp was 60 / 40. Rapid sequence induction was accomplished with 14mg etomidate and 100mg succinylcholine. Bp immediately following induction was 64 / 45. 100 mcg of epinephrine was given without response. Bp fell to 25mmHg and chest compressions begin. A Sternotomy was performed and epinephrine boluses were give. Upon weaning from CPB, BP could not maintain above 70 mmHg. An increase in the epinephrine rate causes ventricular dysrhythmias. Norepinephrine 0. 05mcg / kg / min was instituted contrary to the recommendation of the obstetrician. Bp increased to 110 / 65. Postoperative ultrasound shows fetus with FHR in 120's. The patient carries the fetus to term and delivers a normal, healthy baby boy. Results and Discussions: Hemodynamic compromise is a known complication in Acute valve thrombosis, leading to LV distention and failure, often resulting in death. The Fetal survival rate during CPB only approaches 50%. Infusions of phenylephrine, epinephrine, and norepinephrine all decrease uterine blood flow in pregnant sheep. Phenylephrine has been associated with improved umbilical cord gases at bolus doses up to 50 mcg. No studies exist with use of norepinephrine in pregnancy.

* 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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