Max on Levophed?

NCRNMDM, ASN, RN · Jan 3, 2012

I did some ED and ICU work prior to nursing school, and I am currently a nursing student. I too have heard that there is no max on Levophed, and, while doing my numerous drug cards, I have never encountered something that told me that I could give no greater than x amount of the drug. While there is no max, you should use common sense. If you are running Levophed at a fairly large amount per minute and it isn't working, then it is time to think about adding another pressor rather than constantly upping the dose of your Levophed. I want to be an ICU nurse after I graduate, so I am very interested in all things related to critical care nursing. If your policy states that 40 mcg/min is the maximum, then you can't titrate any higher no matter what kind of order the physician gives you. If I was in this position, I would give the physician a brief overview of how the BP, MAP, heart rate, CO, etc had been trending over the past few hours, and remind him that ICU policy states that Levophed cannot be given at a rate greater than 40 mcg/min. I would politely, but firmly, inform him that I was not going to jeopardize my job or license by titrating the Levophed higher than the policy allowed me to, and I would request that he add another pressor since the Levophed obviously wasn't working, or wasn't working as well as the ICU team would like. If the Levophed wasn't already titrated to 40 mcg/min, I would offer to titrate it to this dose, allow it to take affect, and then inform the physician of the patient's condition. If the condition didn't improve, I would refuse to titrate any higher, and continue to ask for another pressor. Eventually I would go to my charge nurse, explain the situation, and explain that I felt it would be in my patient's best interest if we added another pressor since Levophed alone clearly wasn't doing the job. Patient advocacy is our main job, and we must do whatever we have to in order to ensure that our patients receive the best care possible.

usalsfyre · Jan 3, 2012

Matt, is refusing to go from 40 to 45 mcg/min patient advocacy or advocacy for the facilities policies? Just a thought...

meandragonbrett · Jan 3, 2012

I would politely, but firmly, inform him that I was not going to jeopardize my job or license by titrating the Levophed higher than the policy allowed me to

You have to learn to tread very tactfully when doing this. Please don't be one of those nurses who is quick to throw around "Well it's my license and I can lose it" Everybody will roll their eyes.

Also, don't forget that if a physician truly wants you gone they WILL see to it. They might not have the direct authority to terminate your employment but the Physicians, PAs, and NPs are the ones that MAKE money for the hospital and Nurses COST the hospital money. Just some food for thought there.

You will also find that many policies are outdated, not always evidence based, and just plain make no sense! Getting involved in those practice/policy councils are a must sometimes!

I have never worked in a facility where the policy for levophed was anything other than 100mcg/min max rate.

NCRNMDM, ASN, RN · Jan 3, 2012

While I do feel that we should do everything we can for our patients, I don't feel that breaking facility policy to titrate a drug up by 5 mcg is worth it; especially when this drug hasn't worked in the past, and isn't working at 40 mcg. I hate to be one of the sticklers for the rules, but if the policy says that nurses are not to titrate higher than 40 mcg/min, I'm not going to unless I know for certain that it will work, and I have cleared it with the charge nurse, or whoever is in charge of the unit on that shift. If I have some backup, and I know with great certainty that the titration will work, I may consider breaking the policy. If, however, I find no support amongst my coworkers, and I don't think the titration is going to make a great difference, I'm not putting my job on the line by breaking the policy. In this situation, the patient is doing poorly, is probably declining, and the Levophed isn't working. Sure, breaking the rules might be faster than petitioning for another pressor, but what happens if the 45 mcg/min dose doesn't work, and the patient continues to decline? In the time I wasted deciding to break the rules, titrating the drug up, waiting to see if it worked, and reporting back to the MD, I could've been petitioning the MD, going to the charge nurse (if talking to the doctor didn't work), and starting another pressor.

usalsfyre · Jan 3, 2012

It's not as clear cut as it seems. If you've been going up and the pressures still in the crapper, obviously it's time for a change. It's that difficult time when the pressures been coming up, just not as fast as you would like and acceptable perfusion is "just" within reach that adding a second pressor means wasted time, extra expense and complication, additional weaning ect. Half the unit says go up, the other half bust out with a "not my license" line, and the charge nurse just says "your patient". Now what?

It's the reason hard "ceilings" for drugs such as levophed would be laughable if not so asinine.

NCRNMDM, ASN, RN · Jan 3, 2012

As a nursing student, and someone interested in critical care, I don't think a 40 mcg/min max dose of Levophed is practical. I, personally, think that the policy in that unit needs to be changed. However, when my patient is declining I'm not taking the time to argue outdated policies with someone. In that situation, I am going to tell the physician, "I'm sorry, I'm not trying to be rude, or act like I know it all (because I certainly don't), but I'm really uncomfortable titrating this Levophed any higher. I realize that the policy may be outdated, and it's probably something we should look into changing, but currently our ICU policy states that I can't titrate this any higher than 40 mcg/min. I will titrate the Levophed to the max of 40 mcg/min, see if it is effective, and let you know. If, however, it doesn't work I would like to ask that you give me an order to begin another pressor. I will bring this issue to the attention of the charge nurse, and the director of the unit, and we will examine this policy and see if it would be prudent to change it. For now, however, I am uncomfortable with this, as I feel that it is overstepping my bounds and blatantly breaking the rules set forth by this unit."

meandragonbrett · Jan 3, 2012

Matt,

As usalsfyre has pointed out....it's not always a clear cut decision. Critical Care medicine involved a lot of grey area sometimes. What are you doing to do when your charge nurse says "It's your patient" What are you going to do when it's been 20 minutes and the provider has not called you back but hospital policy states they have 30 minutes to call back before moving up the chain of command? What do you think your charge nurse can do that you aren't able to do as a staff nurse? The provider will not answer any faster if a charge nurse pages them.

NCRNMDM, ASN, RN · Jan 3, 2012

If I was a new ICU nurse, which I hope to be through a new grad critical care residency, I would stick to the unit policy. With no seniority and no credit to my name, I doubt that anyone would rise to support me when the backlash of breaking unit policy fell on me. If I had bee in the unit for quite sometime, had established myself as a competent nurse, and had some credit with the other staff, I would consider breaking policy as a more feasible option.

However, if, as a new grad, I had the support of the unit, and it had been twenty minutes with no response by the physician, I would probably go ahead and titrate up. I want to do the best thing for the patient, but I don't want to lose my job because I tried to protect my patient and broke policy in the process. If it was clear that titrating up would have no positive effect, I would go up the chain of command. If, however, the Levophed was working, but the patient needed more, I would consider titrating if I had support from my coworkers and they could come to my defense when the situation turned ugly.

usalsfyre · Jan 3, 2012

So then protecting policy is more important than patient advocacy?

Matt, please don't take this as busting your chops too hard. Allied health and nursing educational institutions have a way of potraying the delivery of medical care as black and white. The honest truth is CCM, more that any other area of medicine seemingly, is the gray that falls between it. The best I can tell you from my field is breaking policy is fine if you have the evidence to back it up, but I mainly deal with physicians and not nursing administrators. Your approach is probably correct for the new grad, just don't confuse "patient advocacy" with "stuck doing this because it's a stupid policy". If your shoe-horned into the later, fight as much as you can politically to educate those around you and get the policy changed. THAT'S true patient advocacy.

NCRNMDM, ASN, RN · Jan 3, 2012

Also, thank you to both meandragonbrett and usalsfyre for batting this issue around with me. It's great to hear from nurses with experience who can provide perspective, make me think, and cause me to reconsider issues and my responses to them.

NCRNMDM, ASN, RN · Jan 3, 2012

I don't think that at all. I think of it as constructive criticism, which I can always use more of. No, protecting policy isn't anywhere close to protecting the patient and advocating for them. The ICU I did CNA work in before nursing school was small, and linked with a community hospital. The ED was bigger and linked with a larger hospital. In the larger ED, the nurses had much freer reign, and they did what they thought was best. However, at the community hospital these issues rarely came up (the acuity just wasn't that high) and if they did, the nurses didn't have all that much input. I'm not used to dealing with these situations, and I need to learn what the best approach is. If challenging the policy, with the proper evidence and rationale, won't land me in hot water, or cost me my career, then I'm wiling to fight for my patient. I just don't want to come off as the new grad who fights every policy because they think they know more than the rest of the unit.

NCRNMDM, ASN, RN · Jan 3, 2012

To meandragobrett, I hope you got my response. I'm not sure that I sent it correctly, and I don't want you to thank that I did not reply to your message.