What's up with LEVOPHED?

Have you guys noticed an increase in the use of Levophed as a front line medication for hypotension/shock. It used to be the absolute last ditch medication. Remember Lev-o-fed...leave-'em-dead? Did I miss some recently published study?

O_S

Levophed has always been the drug of choice in the right situations from my personal experience.
I'm not sure where that silly rhyme started, but I suspect some smart resident (an oxymoron?)after making some poor decisions decided to blame a medication.
I have worked in CVICU's for almost 15 yrs. and can't imagine not using Levophed when needed.
I believe it got its undeserved reputation from practitioners using it improperly. You MUST ensure your pt.'s hypotension is not the result of hypovolemia. Trying to clamp down on a dry pt. is a recipe for disaster. Preferably you will have a Swan-Ganz catheter but a simple CVP reading via a central line will do in a pinch, and obviously you must have an arterial line to monitor your BP.
If your SVR is 400 and you've dumped fluid in with no increase in BP,Levophed is gonna help that pt. quicker and without the tachycardia Dopamine and Epi bring to the table. Vasopressin? Puleeze, if your pt. is in trouble don't waste time.
Use Levophed, it's a great drug, and monitor your pt.
closely and the only thing left dead will be that old nursing wives tale.

[ QUOTE ]
Hk45c said:
Use Levophed, it's a great drug, and monitor your pt.
closely and the only thing left dead will be that old nursing wives tale.

[/ QUOTE ]

Great post, thanks Hk. Down here in Southeast America Dopamine ruled. Just recently we have seen more and more use of Levo. I knew it was a good drug but to get anyone to use it was pulling teeth. How about Neosynepherine? You guys using much of that?

O_S

My experiences with Levophed is that it isn't as hard on the person's cardiovasc. system...doesn't cause the severe tachy that Dopa can cause when trying have a cardio effect. More alpha, less beta.

Many times, if dopoamine causes tachycardia, we switch to levo and see immediate improvement in HR (and I'm not talking high doses of dopamine either)

Old_School wrote:Have you guys noticed an increase in the use of Levophed as a front line medication for hypotension/shock. It used to be the absolute last ditch medication. Remember Lev-o-fed...leave-'em-dead? Did I miss some recently published study?

O_S

I remember and frequently we still leave-em-dead. Our intensivists prefer Levophed for sepsis and often use it in conjunction with Vasopressin at a constant rate of 0.04 units/min. It doesn't cause the tachycardia that Dopamine does. The third line pressor we use for sepsis is Neosynephrine. After that, we dim the lights, get the tissues and call the family...

R

I agree that the old "Wive's" tale is a bit obsolete and misplaced. I've seen many patients benefit greatly from Levophed, rather than good old Dopamine, because they were already tachycardic. I also like Neo, but have seen a couple of instances in which it caused some pretty severe bradycardia, therefore Levophed has been my personal preference for such patients requiring a pressor without the tachycardia, once fluid resuscitation has been attempted.

Actually at my hospital it was the levophed leave them dead idea up until the last few years or so. I think its because it has less of the cardiac stimulant that dopamine does. I actually preferr Levophed over dopamine because of that aspect. It seems like every time I start dopamine I have a problem with the pt's HR.

I saw somewhere where someone mentioned Vasopressin. Actually I read a short article not too long ago about low dose Vasopressin gtt(0.04units) as second line vasopressor for septic shock. So I imagine we will see more of that as well.

We use a lot of Neosynephrine on my floor. As someone mentioned previously, a big downfall is the bradycardia. We rarely use dopamine, though I have had patients on all three levo, neo, and dopa. The strangest thing I saw was on an organ donor patient, they had us put the patient on a synthroid drip to increase cardiac contractility and all that. The pharmacist gave us a hard time, we had to have the doc and the organ bank rep call them every time the bag ran out. I guess they were either really against organ donation or they didn't get that the patient was already dead.

I love levo. Here in Florida it's used alot and alot of our renal Doc's like to. They've told me that levo is better on kidneys and better with sepsis. :)

We've probably all heard "Levophed, leave 'em dead"

Since Levo constricts blood vessels, extremities are the first effected. We had a patient in neuro icu for so long on levo that her fingers turned black and one of them actually broke off. They should have let that woman die long before that happened.

I did a research paper on necrotizing fasciitis and saw horrid pics of after effects of levo. Ironically two months later, my aunt developed severe abd pain that was disproportionate to the small discoloraton on her abd. Long story short, she had nf and was intubated and on levo in less than 12 hours. Multiple days and surgeries later, I was freaking out-she was still on levophed... Here I am half a continent away and not able to be with her, and I'm thinking the worst. She made it out with all her toes and fingers. She is disfigured from abd through genitals and down to her thighs, but she is going back to full time work this fall and is doing great. Without levo, she would probably not be here with us today!

Baxter drug company when bringing dopamine into the ICU promoted the beta strength of their product. By increasing strength of contraction there was better perfusion than the venoconstriction of levophed. By the way, dopamine received FDA approval as a diuretic not as a vasopressor. The truth is that levophed is a better drug with less tachycardia. The strength of contraction is equal if not better. It is better to keep up than catch up. Perfusion and prevention of Systemic inflammatory response syndrome with its cytokine release is paramount in preventing multi-organ system failure. The use of dopamine early caused levophed to be used as a last ditch drug where it was to late to save the pt. Early use at 100 mcg/kg/min titration up or down depending on response is a better option in the critical pt.

ACEP American College of Emergency Physicians has a great dosing card for Levophed, Epi, Dopamine and Dobutamine. Check it out on ACEP Bookstore - Dose Right Card Adult Vasopressors/Inotropes

We also are using the Levo earlier than we used to, but we have to remember medicine has come a long way and septic patients are recovering mroe than probably anyone would have believed several years ago. There are also the other benefits than using this as opposed to your Dopa, Dobu, vaso, neo, etc.