Detailed Dose Instructions and Comparison for Levophed (Norepinephrine), Nicardipine, and NTG (Nitroglycerin)

The table summarizing the dosage instructions for Levophed (Norepinephrine), Nicardipine, and NTG (Nitroglycerin):

This table provides a quick reference for the dosing and administration of Levophed, Nicardipine, and NTG, ensuring effective and safe use in various clinical scenarios.

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Levophed (Norepinephrine)

1. Standard Preparation and Dosage:
   • Levophed 4 mg in 5% Dextrose Water (DW) 100 ml IV drip:
     • Rate: 3-30 ml/hr, aiming to keep Mean Arterial Pressure (MAP) > 65 mmHg.
     • This is the dose that my routine orders.
   • Levophed 4 mg in 5% Dextrose Water (DW) 250 ml IV drip:
     • Rate: 3-30 ml/hr, aiming to keep Mean Arterial Pressure (MAP) > 65 mmHg.
     • Maximum Rate: 224 ml/hr.
   • 8 mg in 250 ml:
     • Maximum Rate: 112 ml/hr.
   • 16 mg in 250 ml:
     • Maximum Rate: 56 ml/hr.
   • Peripheral Drip (4 mg in 100 ml):
     • Rate: 3-60 ml/hr.
   • Peripheral Drip (8 mg in 100 ml): Central line required.
     • Rate: 3-60 ml/hr.
2. Dosage Adjustments:
   • 8 mg in 250 ml:
3. Pediatric and Adult Dosing:
   • Infants (GA >35 weeks): Start 0.2-0.5 mcg/kg/min, adjusting every 30 minutes up to 0.2-2 mcg/kg/min.
   • Children: Start 0.05-0.1 mcg/kg/min, increasing gradually up to 1-2 mcg/kg/min.
   • Adults: Start 4 mcg/min, increasing gradually up to 8-12 mcg/min.
   • ACLS Guideline: Start 0.1-0.5 mcg/kg/min.
   • Refractory Shock: 8-30 mcg/min.
4. Precautions:
   • Administer through a large vein to avoid extravasation.
   • Concentration typically 4 mcg/ml, can be increased to 16 mcg/ml for fluid-restricted patients.
   • Do not mix in NSS; avoid contact with bases like Sodium Bicarbonate (NaHCO3).

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Nicardipine

• Standard Preparation and Dosage:
  • Nicardipine 2 mg IV stat: Repeat based on BP monitoring.
  • Subsequent Dose: Nicardipine 1-2 mg IV stat or Labetalol 10 mg IV for stroke post-rtPA, keeping BP < 180/105.
• Infusion Protocols:
  • Nicardipine 20 mg (in 20 ml) + NSS 80 ml (1:5) IV drip:
    • Rate: 10-70 ml/hr.
    • Titration: Increase by 5 ml/hr every 5-15 minutes.
    • For Stroke: Start at 20-25 ml/hr, titrate as needed.
  • Nicardipine 12 mg + 5% DW 100 ml (1:10) IV drip:
    • Rate: 10 ml/hr (1 mg/hr).
• Pediatric and Adult Dosing:
  • Neonates: Start 0.5 mcg/kg/min, maintaining 0.5-2 mcg/kg/min.
  • Children: Start 0.5-1 mcg/kg/min, adjusting every 15-30 minutes up to 0.5-4 mcg/kg/min.
  • Adults: Start at 5 mg/hr, increasing by 2.5 mg/hr every 5-15 minutes. Max 15 mg/hr.
  • Subarachnoid Hemorrhage: 0.15 mg/kg/hr for 14 days.
• Precautions:
  • Rapid Titration: Especially in stroke, start rate at 20-25 ml/hr and titrate as needed.
  • Heart Failure or Renal Impairment: Adjust dosage carefully.

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NTG (Nitroglycerin)

• Standard Preparation and Dosage:
  • NTG 50 mg (10 ml) + NSS 115 ml (1:2.5) IV drip:
    • Rate: 3-30 ml/hr, aiming to keep systolic BP < 140 mmHg and HR < 110 bpm.
  • NTG 20 mg + 5% DW/NSS 100 ml (1:5) IV drip:
    • Rate: Start 5-10 ml/hr.
    • For Hypertension (HT): Titrate to a fixed maximum tolerated dose, ensuring BP does not drop excessively.
    • For Myocardial Infarction (MI): Titrate by 1.5 ml/hr (5 mcg/min) every 10-15 minutes. If reaching a rate of 9 ml/hr (30 mcg/min), increase by 3 ml/hr (10 mcg/min). If exceeding a rate of 15 ml/hr (50 mcg/min), monitor for arterial dilation and risk of hypotension. Max rate: 30-45 ml/hr (100-150 mcg/min).
• Dosage Adjustments and Special Instructions:
  • For Heart Failure from MI or HT Emergency, Malignant HT:
    • Avoid in RV systolic dysfunction, hypovolemia, or HF with BP drop. If wet-cold BP is good, use NTG.
    • For wet warm HF, titrate to max dose (rate 30 ml/hr) or as tolerated, maintaining BP. Continue for 48 hours before titrating down.
  • Avoid Reflex Tachycardia: Careful in vasodilators like nitroprusside, NTG, and nicardipine, especially avoiding use in aortic dissection.
• Pediatric and Adult Dosing:
  • Infants and Children: Start 0.25-0.5 mcg/kg/min, increasing by 0.5-1 mcg/kg/min every 3-5 minutes as needed. Usual range: 1-3 mcg/kg/min, max 5 mcg/kg/min, can go up to 20 mcg/kg/min if necessary.
  • Adults: Start 5 mcg/min, increasing by 5 mcg/min every 3-5 minutes up to 20 mcg/min. If unresponsive, increase by 10 mcg/min every 3-5 minutes up to 200 mcg/min.
• Precautions:
  • Monitor for hypotension and reflex tachycardia.
  • Avoid in RV systolic dysfunction, hypovolemia, HF with BP drop unless BP is stable.

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Comparison summary

• Levophed: Used primarily for maintaining MAP > 65 mmHg. Various infusion concentrations and rates are based on patient needs and vascular access.
• Nicardipine: Primarily for managing BP in hypertensive emergencies, especially stroke. Different infusion rates are based on concentration.
• NTG: Used in managing BP in emergencies and heart failure. Careful titration is required to avoid hypotension.

Understanding these dosage instructions and their clinical applications ensures the effective and safe use of Levophed, Nicardipine, and NTG in various medical scenarios.