Use of Vasopressin

[sidabcd]

For a patient with septic shock having a central line, at what dose of levophed would you consider adding vasopressin if the MAP goal of 65 is not maintained? Would you add if levophed is at 15 mcg/min or wait until it max out at 30 mcg/min?

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[jdh71]

Depends on how sick they look.

I don’t know who isn’t dosing norepi by weight in 2020 . . . But in general once you get to 0.2mcg/kg/min is when I start in a patient who is escalating in pressor needs and I’ve convinced myself is adequately intravascularly resuscitated at that time. This also usually when I’ll add hydrocortisone as well.

There is no such thing as “max dose levophed”. This is a nursing notion based on the order given to them for titration. You’re flogging alpha1. You can anyways go UP. There are pluses and minuses to this and of course a theoretical saturation point. But the reason you add Vasopressin isn’t because norepi got “maxed” but rather you are interested in increasing MAP by adding a receptor activation.

 

[Doctor Bob]

For a patient with septic shock having a central line, at what dose of levophed would you consider adding vasopressin if the MAP goal of 65 is not maintained? Would you add if levophed is at 15 mcg/min or wait until it max out at 30 mcg/min?

I add it at 0.1 mcg/kg/min. I'm at least paying lip service to the findings of the VAAST study which suggested that you got benefit from starting it early.
Max dose levophed? As @jdh71 said, the limit is institution dependent. We stop at 3 mcg/kg/min because there's diminishing returns after 1 mcg/kg/min, and after 3 the presets on the pumps no longer work. Could you go higher? Sure. You could put the bag on a rapid infuser but... I wouldn't recommend it.

 

[chocomorsel]

I add it at 0.1 mcg/kg/min. I'm at least paying lip service to the findings of the VAAST study which suggested that you got benefit from starting it early.
Max dose levophed? As @jdh71 said, the limit is institution dependent. We stop at 3 mcg/kg/min because there's diminishing returns after 1 mcg/kg/min, and after 3 the presets on the pumps no longer work. Could you go higher? Sure. You could put the bag on a rapid infuser but... I wouldn't recommend it.

That is a huge amount of levophed no? As in turn your insides black and toes fall off kinda levophed.
Every hospital I have been to still does mcg/min for pressors in the ICU Unless it’s an anesthesiologist run ICU. In the OR we have always used mcg/kg/min which has always made more sense to me as mcg/min doesn’t usually mean much in our obese population.

 

[Doctor Bob]

That is a huge amount of levophed no? As in turn your insides black and toes fall off kinda levophed.
Every hospital I have been to still does mcg/min for pressors in the ICU Unless it’s an anesthesiologist run ICU. In the OR we have always used mcg/kg/min which has always made more sense to me as mcg/min doesn’t usually mean much in our obese population.

The 3 mcg/kg/min? Yea, it's a ridiculous amount of levo. It's physiologically useless at that level, but it makes the numbers on the monitor look nice for a short time. We only ever reach those levels when there's a family issue.

I'm surprised you're still finding a lot of places where they do mcg/min in the ICU. Smaller hospitals practicing 10-20yr old critical care medicine, sure, but places with a good pharmacy presence and especially academic places should have converted over to weight-based dosing for almost all pressors.

 

[chocomorsel]

The 3 mcg/kg/min? Yea, it's a ridiculous amount of levo. It's physiologically useless at that level, but it makes the numbers on the monitor look nice for a short time. We only ever reach those levels when there's a family issue.

I'm surprised you're still finding a lot of places where they do mcg/min in the ICU. Smaller hospitals practicing 10-20yr old critical care medicine, sure, but places with a good pharmacy presence and especially academic places should have converted over to weight-based dosing for almost all pressors.

Yeah, I work mostly in community hospitals that have 200-400 beds. I absolutely hate academics and haven't gotten much locums work in large hospitals.