Max on Levophed? - page 4
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... Read More
Jan 3, '12I will look into the AACN, it sounds like a great way to gain more knowledge. I will also look at Google scholar to see what I can find.
Jan 3, '12http://www.guideline.gov/browse/by-topic.aspx
This is also a great website for guidelines for a variety of diseases that include levels of evidence and references
Jan 3, '12I don't think I would ever have the nerve to tell someone else that they were doing a procedure incorrectly when it wasn't harming the patient. If I had knowledge that there was a better procedure or drug for the patient, I would share that. If the current drug or procedure isn't harming the patient, and is being properly used or executed, then there's no reason to get picky and assert that there is one correct way to do it, and that my way is better. I think that's being a little too forward and arrogant, frankly.
Jan 3, '12Oh well. Can't find it. Going to sleep. Maybe I will wake up tomorrow and someone else will have. Good night everyone. Thanks for the enlightening discussion!
Jan 3, '12[QUOTE=usalsfyre;6015287]Esme, I would hope there's a difference between doing something like giving a med through an A-line
(which your not going to find supported in medical literature anywhere) uhm......http://hyper.ahajournals.org/content/33/1/36.full.pdf
and giving a dose of medication where there's wide variation of the "max". While I can see a firing, a nurse losing her license would be draconian. What makes more sense, going to 42mcg/min to get an acceptable MAP or adding another agent to wean from? This is why in the out-of-hospital word there's been a push away from "protocols and policies" to "guidelines".[/QUOTE
They give epi on pump all the time. I guess I should have been more specific as the patient was on a bi-vad and that is where the med was to be given and yea we all had seen it given and work there was just no MD on that side of the room to give it through the machine. Grant it this was in the stone age when we, the nurses, took care of these machines ourselves and the perfusionist was on the job training tech, hence the old term "pump tech". The point was to make don't so it even if the MD screams at you becuse you are responsible for everything that you do and give.
Nurses lose their licenses everyday and it's not just because of drugs(personal abuse). How about that nurse that makes a drug error with an untoward outcome not following procedure or even if they followed procedure. If you don't follow procedure it makes it criminal.
This nurse by reports followed procedure and still made a deadly mistake...
Nurse suicide follows infant tragedy
New York City Infant Dies From Antibiotic Overdose - Nurse Discharged
Baby's death spotlights safety risks linked to computerized systems
I would never advise anyone to practice outside of policy and procedures in a hospital. Guidelines are your friend.....they are there to provide consistant SAFE practice of medicine. Those policies are there to protect the nurses from cowboy MD's who practice wayward medicine. I agree that more is not always better and maybe it's time to switch. while LEVO has been given high does for extended peroids of time at larger teriary facilities....where there is a larger 24/7 coverage (in house) and responsibility other than the ED doctor or hospitalist. So if your hospital, agency,ambulance says no the answer should be no. jmho...Peace
Jan 5, '12Wow! Thank you everyone for your responses! I'm reading a lot of the articles you have posted and appreciate your responses! I do need to clarify though, as 40mcg/min is what our hospital -recommends- as the max and physicians are allowed to order a different max for drips, it is not per say the policy and if I had an order I could go as high as the physician ordered me to.
Thanks again everyone and keep up the discussion
Jan 12, '12Our hospital said 30, but a few doctors say there is no max. you can go as high as you need. May have no extremities left, but probably if they need that high of a dose, it's life over limb......
Jan 17, '12I was thinking the 30-40 had more to do with risk of limb loss than anything else. We have a limit of 80, and we've had docs that would come in and crank it up until the patient's feet and hands were purple trying to maintain perfusion to the brain. The patients always died when they needed levo set that high (our ICU's in the middle of no where, if you're in an ICU in a flagship hospital, this may be normal for you guys).
FYI. If any of you guys are my nurse and they are discussing cranking up levo vs. epi vs. neo --- just shoot me. We've got some folks that are basically cadavers with a heart beat because of all the pressors they are on, and that just gives me the heebie-jeebies.
Jun 22, '13Hey Belgian RN,
I would like to correct some of things said.
Neo gives relatively more venous vasoconstriction thus increasing preload somewhat more than levophed does. Sometimes that can convince them to add Neo instead of pusing more levophed.
I do agree that vasoconstriction increases preload. However, increasing preload by vasoconstricting its detrimental for the patient. An increase in fluid status increases your END DIASTOLIC VOLUME which increases your stroke volume.
Therefore, your preload increases. However, when you increase your levophed/neo up vasoconstrictions occur thus your afterload increases. This increased afterload increases your END SYSTOLIC VOLUME which may reflect an adequate preload but inadequate or decreased stroke volume.
Also, even though levophed has beta receptors, the alpha receptors take complete control thus the beta receptors do not play a role.
Every septic patient should be on vasopressin regardless.Last edit by Esme12 on Jun 25, '13 : Reason: Formatting
Jun 25, '13It still depends .....every practitioner has different theories and allnurses is an international site and we have many international members. Medicine isn't always consistent.
Jul 24, '13Our pumps warn us at 100. Hard limit is 150. I've been told I can go as high as 200 but the pump wound't let me. So...150 it is. These are the people who are profoundly septic/bleeding out/actively dying. the last one I had was on the levo, vaso at 0.04, epi at 20 which is our pumps hard max, all to get a MAP around 63. Ended up in SVT so bye bye epi! Also ended up dying, obviously.