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Calcium Sensitiser / Inodilator Pregnancy: Avoid

Levosimendan

Brand names: Simdax

Adult dose

Dose: Loading: 6–12 mcg/kg over 10 minutes (omit if hypotensive), then 0.05–0.2 mcg/kg/min infusion for 24 hours
Route: IV infusion
Frequency: Single 24-hour infusion
Max: 0.2 mcg/kg/min
For acute decompensated heart failure with reduced cardiac output. Haemodynamic effects persist 7–9 days due to active metabolite (OR-1896).

Paediatric dose

Dose: 0.1 mcg/min/kg
Route: IV infusion
Frequency: Continuous
Max: 0.2 mcg/kg/min
Concentration: 2.5 mg/mL diluted to 0.025–0.5 mg/mL mcg/min/ml
Off-label paediatric use; specialist cardiac ICU only. Loading dose 6 mcg/kg over 10 min.

Dose adjustments

Renal

Caution in severe renal impairment — metabolite accumulates

Hepatic

Caution in severe hepatic impairment

Paediatric weight-based calculator

Off-label paediatric use; specialist cardiac ICU only. Loading dose 6 mcg/kg over 10 min.

Clinical pearls

  • Unique mechanism: sensitises troponin C to calcium without increasing intracellular Ca2+ (no proarrhythmic effect seen with dobutamine)
  • RUSSLAN/SURVIVE trials: no mortality benefit over dobutamine but haemodynamic improvement
  • Effects persist 7–9 days after infusion due to active metabolite OR-1896
  • Consider in patients on chronic beta-blocker therapy (less attenuated response vs dobutamine)

Contraindications

  • Significant mechanical obstruction to ventricular filling/ejection
  • Severe hypotension (SBP <85 mmHg)
  • Tachycardia >100 bpm
  • Severe renal or hepatic failure

Side effects

  • Hypotension
  • Tachycardia
  • Headache
  • Hypokalaemia
  • VT (rare)
  • QT prolongation

Interactions

  • IV nitrates — profound hypotension
  • Digoxin — additive effects on rhythm
  • QT-prolonging drugs — increased risk
  • Antihypertensives — additive hypotension

Monitoring

  • Blood pressure (continuous)
  • Heart rate
  • ECG
  • Electrolytes (especially potassium)
  • Signs of hypoperfusion

Reference: BNFc; RUSSLAN Trial 2002; SURVIVE Trial (Mebazaa et al, JAMA 2007); BNF. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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