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Norepinephrine Bitartrate Injection is a concentrate, potent drug which must be diluted in dextrose containing solutions prior to infusion. Infusion of LEVOPHED should be given into large vein. Blood volume depletion should always be correct as fully as possible before any vasopressor is administer. When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, LEVOPHED can be administered before and concurrently with blood volume replacement. Average Dosage: Add 4 mL ampul of LEVOPHED To 1 000 mL of 5 percent dextrose containing solution. Each mL of this dilution contains 4 mcg of base of LEVOPHED. Give this solution by intravenous infusion. Insert plastic intravenous catheter through suitable bore needle well advanced centrally into the vein and securely fix with adhesive tape, avoiding, if possible, catheter tie - in technique as this promotes stasis. A drip chamber or other suitable metering device is essential to permit accurate estimation of the rate of flow in drops per minute. After observing response to an initial dose of 2 mL to 3 mL per minute, adjust the rate of flow to establish and maintain low normal blood pressure sufficient to maintain circulation to vital organs. In previously hypertensive patients, it is recommended that blood pressure should be raised no higher than 40 mm Hg below preexisting systolic pressure. The average maintenance dose ranges from 0. 5 mL To 1 mL per minute. High Dosage: Great individual variation occurs in the dose required to attain and maintain adequate Blood Pressure. In all cases, dosage of LEVOPHED should be titrated according to the response of the patient. Occasionally, much larger or even enormous daily doses may be necessary if patient remains hypotensive, but occult blood volume depletion should always be suspect and correct when present. Central venous pressure monitoring is usually helpful in detecting and treating this situation. Fluid Intake: degree of dilution depends on clinical fluid volume requirements. If large volumes of fluid are needed at a flow rate that would involve excessive dose of pressure agent per unit of time, solution more diluted than 4 mcg per mL should be used on other hand, when large volumes of fluid are clinically undesirable, concentration greater than 4 mcg per mL may be necessary. Duration of Therapy: infusion should be continued until adequate Blood Pressure and tissue perfusion are maintained without Therapy. Infusions of LEVOPHED should be reduced gradually, avoiding abrupt withdrawal. In some reported cases of vascular collapse due to acute myocardial infarction, treatment was required for up to six days. Infusions of LEVOPHED are usually administered intravenously during cardiac resuscitation. To restore and maintain adequate blood pressure after effective heartbeat and ventilation have been established by other means. Average Dosage: To maintain systemic Blood Pressure during management of cardiac arrest, LEVOPHED is used in the same manner as described under Restoration of Blood Pressure in Acute Hypotensive States.
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. Get emergency medical help if you have signs of allergic reaction: hives; difficult breathing; swelling of your face, lips, tongue, or throat. Pain, burning, irritation, discoloration, or skin changes where injection was give; sudden numbness, weakness, or cold feeling anywhere in your body; slow or uneven heart rate; blue lips or fingernails, mottle skin; little or no urination; trouble breathing; problems with vision, speech, or balance; or severe headache, blur vision, pounding in your neck or ears. This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1 - 800 - FDA - 1088.
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.
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.
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.
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