Levosimendan Infusion Rate Calculator

About This Levosimendan Infusion Rate Calculator

This Levosimendan Infusion Rate Calculator converts a weight-based dose into a pump rate in mL/hr for the two standard dilutions of levosimendan (Simdax) 2.5 mg/mL concentrate. It returns the optional loading dose, the maintenance rate across the full licensed titration range, and the 24-hour volume for each step so that the number of 500 mL bags required for a complete course is immediately apparent.

Levosimendan occupies an unusual position among inotropes. It is approved in many European and Latin American countries but is not approved by the US FDA, and it does not hold a UK marketing authorisation — in the UK it is obtained as an unlicensed import — so it is absent from most North American dosing references. It is also mechanistically distinct: rather than raising intracellular calcium through β-receptors or phosphodiesterase inhibition, it sensitises cardiac troponin C to calcium already present, producing inotropy without a meaningful rise in myocardial oxygen demand, while opening ATP-sensitive potassium channels to produce arterial, coronary and venous vasodilation.

The Formulas Explained

Loading Dose (Optional)

The product information permits 6–12 mcg/kg over 10 minutes, and specifies the lower 6 mcg/kg dose for patients already receiving intravenous vasodilators or inotropes. This tool defaults to no loading dose, which reflects both the hypotension risk and the design of every large contemporary trial.

Continuous Infusion Rate

The two supplied dilutions are 0.025 mg/mL (25 mcg/mL, made by adding 5 mL of concentrate to 500 mL of 5% glucose) and 0.05 mg/mL (50 mcg/mL, made by adding 10 mL to 500 mL of 5% glucose). Outputs from this levosimendan dosing calculator have been cross-checked against the manufacturer’s published weight-based infusion tables across the 40–120 kg range for both dilutions.

Clinical Interpretation & Limitations

Start at 0.1 mcg/kg/min and reassess the patient during the loading dose or within 30–60 minutes of any adjustment. If the response is excessive — hypotension or tachycardia — reduce to 0.05 mcg/kg/min or stop. If the initial dose is tolerated and a greater haemodynamic effect is needed, increase to 0.2 mcg/kg/min. The recommended duration is 24 hours; no tolerance or rebound has been observed on discontinuation.

The clinically distinctive feature is persistence. Because the active metabolite OR-1896 has a half-life of 75–80 hours and reaches peak plasma concentration roughly 2 days after the infusion is stopped, haemodynamic effects continue long after the pump is disconnected. Blood pressure effects generally last 3–4 days and heart rate effects 7–9 days. Non-invasive monitoring for at least 3 days after the end of the infusion is recommended, extending to at least 5 days in mild-to-moderate renal or hepatic impairment, where metabolite concentrations rise further; some institutional protocols continue ECG, blood pressure and electrolyte monitoring for 7–10 days in these patients.

Administer the continuous infusion through central venous access using an infusion pump, ideally with medication-error-reduction software enabled. Avoid administering levosimendan in lines where other drugs or fluids may be bolused or flushed, as an inadvertent bolus can precipitate hypotension. Because the drug is a potent vasodilator, concomitant nitrates such as isosorbide mononitrate significantly potentiate orthostatic hypotension and should prompt closer haemodynamic observation.

Limitations

• This Levosimendan Infusion Rate Calculator assumes an adult patient and the two standard dilutions above. It performs no renal or hepatic dose adjustment, because the product information specifies none — instead, severe impairment is an outright contraindication.
• Evidence outside acutely decompensated heart failure is not supportive. LEVO-CTS, CHEETAH and LICORN each failed to demonstrate benefit in cardiac surgery, and the 2026 Surviving Sepsis Campaign guideline recommends against use in septic shock. Perioperative and shock use remains off-label.
• The concentrate contains a high proportion of ethanol as an excipient, which is relevant in patients with alcohol dependence, hepatic disease or epilepsy.
• Hypotension is the dominant adverse effect, and baseline systolic pressure below 100 mmHg or diastolic below 60 mmHg was identified in a post-hoc analysis of REVIVE II as a factor increasing mortality risk. Clinical judgement about haemodynamic suitability sits outside this tool.

Frequently Asked Questions (FAQ)

1. Should I give a levosimendan loading dose?

Often no. The product information permits an optional 6–12 mcg/kg bolus over 10 minutes, and specifies the lower 6 mcg/kg dose when the patient is already receiving intravenous vasodilators or inotropes. However, LICORN, LEVO-CTS and CHEETAH all omitted the bolus entirely; the LICORN investigators stated this was done to avoid excessive vasodilation in a fragile population. Omitting it is the safer default in hypotensive patients.

2. How is levosimendan diluted for infusion?

Add 5 mL of the 2.5 mg/mL concentrate to 500 mL of 5% glucose for a 0.025 mg/mL infusion, or 10 mL to 500 mL of 5% glucose for 0.05 mg/mL. Only 5% glucose is specified as the diluent. The diluted solution should not be stored or infused beyond 24 hours, and the concentrate is for single use only.

3. How long should the infusion run, and what happens after it stops?

Twenty-four hours is the recommended duration in acute decompensation of severe chronic heart failure. Effects then persist for days through the active metabolite OR-1896: blood pressure effects for 3–4 days and heart rate effects for 7–9 days. Non-invasive monitoring for at least 3 days after the infusion ends is recommended, or at least 5 days with mild-to-moderate renal or hepatic impairment.

4. What is the maximum infusion rate?

0.2 mcg/kg/min is the maximum within the recommended maintenance range of 0.05–0.2 mcg/kg/min. Rates at or above 0.4 mcg/kg/min, and infusions beyond 24 hours, increase heart rate and are sometimes associated with prolongation of the QTc interval. This Levosimendan Infusion Rate Calculator therefore stops at 0.2 mcg/kg/min.

5. Can levosimendan be used after cardiac surgery or in septic shock?

Both are outside the licensed indication. In cardiac surgery, LEVO-CTS, CHEETAH and LICORN were all neutral for their primary endpoints. For septic shock, the 2026 Surviving Sepsis Campaign guideline recommends against levosimendan. The manufacturer also notes that use in cardiogenic shock has not been studied.

6. Who should not receive levosimendan?

It is contraindicated in creatinine clearance below 30 mL/min, severe hepatic impairment, severe hypotension with tachycardia, significant mechanical obstruction affecting ventricular filling or outflow, a history of Torsades de Pointes, and known hypersensitivity. It is not recommended under 18 years of age. Low serum potassium and severe hypovolaemia should be corrected before starting.

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