Vasopressors and inotropes
Norepinephrine (Levophed) drip
Levophed
Watch the explainer
Dosing
| Start | 2–12 mcg/min (about 0.02–0.15 mcg/kg/min) |
|---|---|
| Titrate | 1–2 mcg/min (0.01–0.05 mcg/kg/min) every 5 minutes to the MAP goal |
| Maximum | No fixed maximum. Rising past about 0.25–0.5 mcg/kg/min: add vasopressin (SSC 2021; SSC 2026 sets no threshold) |
| Common bags | 4 mg in 250 mL (16 mcg/mL); 8 mg in 250 mL (32 mcg/mL); 16 mg in 250 mL (64 mcg/mL) |
| Dose units | mcg/min, mcg/kg/min |
Line and administration
- Central line preferred; peripheral is acceptable short term in a large proximal arm vein with frequent site checks
- Extravasation: stop, aspirate, phentolamine 5–10 mg in 10–15 mL saline injected into the area
Watch for
- Arrhythmias
- Digital, limb and gut ischemia
- Treat hypovolemia alongside
Norepinephrine: full drug monographIndications, mechanism, pharmacokinetics, cautions and every dose the app lists.
In the one-pagers
- Vasopressors and InotropesReceptors and effects: Norepinephrine: α1 > β1 (little β2): ↔ / ↑ / ↑↑
- Shock Types at a GlanceFindings and first treatments: Cardiogenic: Cool, mottled; crackles, JVD; low urine output: Reperfuse an MI; norepinephrine; add an inotrope; MCS if failing
- Sepsis and Septic Shock BundleVasopressors and MAP: 1st: Norepinephrine: First-line; may start peripherally
- After Cardiac SurgeryTamponade, low output or vasoplegia?: Vasoplegia: MAP under 65, CI over 2.2, SVR under 800 (risks: long bypass, preop ACE inhibitors). Norepinephrine plus vasopressin; if refractory, methylene blue 1 to 2 mg/kg (serotonin syndrome with SSRIs, falsely low SpO2, G6PD hemolysis) or hydroxocobalamin 5 g (red urine, lab interference, CRRT blood-leak alarms). Follow your institution's protocols.
- Pulmonary EmbolismSupporting the failing RV: Norepinephrine first: keeps aortic above RV pressure; vasopressin second
- Right Heart Failure and Pulmonary HypertensionManagement priorities: Pressure: norepinephrine, then vasopressin; MAP 65 or more (WSPH 2024: 70–75), aortic above PA pressure.
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For education and exam preparation only. Follow your institution’s protocols. Study aid: check every dose against the order, the bag label, your pump library and your institution's protocol.