Max on Levophed?

Specialties CCU

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Hi!

I'm a fairly new ICU RN and recently had a doctor tell me there is no max on Levophed. Our hospital policy states that the recommended max is 40mcg/min. The doctor refused to give me a second pressor because he said that studies have shown there is no difference. I want to research this better but a google search hasn't turned up anything... thoughts?

Specializes in critical care, PACU.

Matt,

At the bedside you will find yourself throwing the policies out the window if your patient's bp is 60 and levophed is "maxed." Hell, you might even find yourself starting the levophed without an order. You won't let your patient die for the sake of policy.

If it were me, I would titrate up and then let the MD know that we've reached the max and could we add another pressor or bolus some albumin at this point. I've always found the mds to be willing to add another drip and go with the rules.

House supervisors are a great resource especially for nights, which you will probably find yourself working if you want to do ICU as a new grad. I would just contact them with the approval of my charge nurse if the md was adamant about breaking policy. House soup will either approve it and you know the responsibility is now with them or they will contact the MD themselves and work it out.

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Thank you for this reply. What you said makes sense, and it sounds like the best plan. If I could get it cleared by the house supervisors, then I would be willing to go with the MD and break any policy if I thought it would benefit my patient. Thanks for giving me your advice on the situation, and letting me know what you would do. That really helps me see what the best practice is in this situation. Since the unit concerned in this post has a Levophed max of 40 mcg/min would it be okay to go ahead and titrate to that without consulting anyone? I assume the answer to this is yes, since it is a unit policy and the patient is in extremis.

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Specializes in critical care, PACU.

I went straight into the ICU as a new grad and I'm super paranoid as it is. So I've always just asked my charge nurse (and/or house soup) whenever something is uncomfortable. Even if I already know what I am going to do, I check with them. It's a way to learn how they would do it and also to have someone in your corner in case your boss or the MD is upset. I had a really punitive boss, so whenever I felt I was even slightly breaking policy, I made sure I had some senior people who agreed with me. You could still get thrown under the bus, though, but just don't do anything illegal and don't kill your patient and you should be okay.

To answer your question...

The short answer: As the nurse you can titrate however you want up until 40 without "breaking policy"

Long answer:

You will get more and more comfortable with titrating drips as you learn through trial and error in addition to what you already know. I think I posted a thread a while back about how worried I was about drip titration because books don't really tell you "Okay increase the drip this much now and then stop then and then decrease when..."

You'll learn when you have been too aggressive and you overshot your BP and when you need to be more aggressive when your bp doesn't respond quickly enough. And you'll also learn that this can vary depending on the patient.

When I first started, I would go to someone I trusted and tell them why I wanted to increase the drip after I increased it to see if they agreed. Usually they would. And if they didn't, I learned something. It might seem like excessive checking, but I think seeing other people's rationales and not just increasing it whenever I felt like it helped me gain confidence with titration.

And if the BP dropped rapidly or the rhythm suddenly couldn't support a good BP or for whatever reason, you bet I had enough confidence to increase the drip without checking with anyone. That's important too.

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Thanks for your answer. I thought you could titrate up until you reached your maximum limit without breaking policy, but I wanted to make sure. I feel like I will be exactly like you where when you started, but I think it's better to be paranoid than to be cocky and overconfident. I do feel that I will become more confident as I gain experience with titrating drips and managing a patient with a changing hemodynamic status. I don't mind being thrown under the bus for helping my patient as long as someone is in my corner, and I'm not in the position where no one will defend my actions.

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Specializes in CCT.

Better than having people's opinions to defend your actions have hard evidence, aka EBM.

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Thanks, Good suggestion. Would this hard evidence be something like discouraging the use of Levophed for a specific patient because it can cause arrhythmias and reflex bradycardia and using this information to back up your decision?

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Specializes in critical care, PACU.
Better than having people's opinions to defend your actions have hard evidence, aka EBM.

Of course that too. When I graduated I was exceedingly "book smart" and I still read a lot of journal articles. It sounds like Matt is like this too. Asking others how they would do things and then making an educated decision based upon their input, your feelings, and of course science is how I was able to grow my "street" smarts.

The sad truth is, when you're new, your boss doesn't give a damn about EBP. They want to know that you didn't go all cowboy nursing on them and did a whole bunch of crap without involving the charge nurse. At least, that was my experience.

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Specializes in critical care, PACU.
Thanks, Good suggestion. Would this hard evidence be something like discouraging the use of Levophed for a specific patient because it can cause arrhythmias and reflex bradycardia and using this information to back up your decision?

The hard evidence would be that after a certain point, levophed has not been shown to be increasingly effective with increased doses.

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That's what I'm afraid of in a way. I don't want to be seen as the reckless new grad nurse who is so cocky and confident that he just does as he sees fit, because that is not how I am. As much as I would love to use science, educated decisions, EBP, and my knowledge from nursing school in combination, I feel like this wouldn't be smiled on in some facilities. I think that, at some hospitals, critical care units don't like new graduates who use EBP to say that more experienced nurses and doctors aren't making the best choices regarding treatment of a patient. I don't think it should be this way, but I get the impression that it is that way in many units.

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Okay, I understand. What type of journals/publications do you find information like this? I'm interested in reading these types of articles, and storing this information in case I have the opportunity to use it as a new grad. As I said in my other post, I don't want to come off as cocky, but in a unit where I could use EBP as a new grad, I would love to be able to.

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Specializes in critical care, PACU.
That's what I'm afraid of in a way. I don't want to be seen as the reckless new grad nurse who is so cocky and confident that he just does as he sees fit, because that is not how I am. As much as I would love to use science, educated decisions, EBP, and my knowledge from nursing school in combination, I feel like this wouldn't be smiled on in some facilities. I think that, at some hospitals, critical care units don't like new graduates who use EBP to say that more experienced nurses and doctors aren't making the best choices regarding treatment of a patient. I don't think it should be this way, but I get the impression that it is that way in many units.

Yep. This is what I experienced too. It's all about balance--knowing when to pick your battles, when it's important to assert your knowledge and when it's not. EBP is very important, but you can also learn alot from the experienced nurses.

I'm trying to track down an article that says when exactly levo stops being increasingly effective with increased doses so we can get a legit number here for the discussion. If anyone else finds it first, please share to save us the time ;)

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Specializes in critical care, PACU.
Okay, I understand. What type of journals/publications do you find information like this? I'm interested in reading these types of articles, and storing this information in case I have the opportunity to use it as a new grad. As I said in my other post, I don't want to come off as cocky, but in a unit where I could use EBP as a new grad, I would love to be able to.

You should join the AACN. They give a student discount. They will send you two different publications I forget the exact frequency. It's a good way to keep up to date.

I also like to check up on this website Medscape: Medscape Access

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