[rph3664]

We have made octuple strength Levophed drips, although they were usually cases of people on numerous other drips AND fluid restriction.

I don't know how high the titration went since in the pharmacy, we just make them as the need arises.

Once we get to double strength, we know there's a pretty good chance the patient won't make it.

[RNFELICITY]

Originally Posted by Diary/Dairy

Last thing - You do what you can - document what you did - not all of them live though - you gotta leave that behind at work. Mourn the loss of life, but know that you cannot save them all.

And this is probably the hardest thing to get under control...we can't save everyone adn second guessing what we did or didn't do is like being a monday night quarterback. Learn and grow from the experience. ((HUGS))

[Diary/Dairy]

Yeah it is - There is the guilt, the did-I-miss-something feeling....

Somedays its easier to let them go, sometimes it still makes me cry. Just part of being human.

[gradcare]

38 with ccf. bad karma from the get go. You do what you can with what you've got. what was the ecg like? any chance that this was pure pump failure cardiogenic shock)? Any SVO2/ mixed venous / subclavian gases to differentiate between sepsis/ cardio shock?.

The other thing to remember is that you are only able to make the calls based on your experience and knowledge. I've been playing in the ICU for a while and would have had difficulty keeping this pt in the world of the living.

One final thing don't beat yourself up. You gave the attending doc's the information you had, if they need more they ask for more. II'm hoping your shift coordinator gave you some help as well, they are meant to suplement your knowledge and skills when things get tough. Finaly I've run 200 mcg/min norad levo plus 85mcg/min adrenaline (epi) with Vaso, dobutamine and balloon pump before. They survived until we could get them on a LVAD but didn't make it to the top of the heart transplant list.

Stick with it . You did ok with what you had. This pt has taught you heaps about ICU, nursing and yourself, don't waste it. This pt will live on (sort of) in the lesson's that you have learned.

Sorry if post is scrambled but have just finished nite ending as it started with a code and a threatened airway.
Cheers

[CVICURN2003]

I am sorry you had a bad night. I ahve had levo running at 100 ML/hr, Vasopressin at 30 ml hour (3x normal dose) and EPI at 100 ml hour plus giving epi boluses, plus given blood, plus a gazillion liters of fluid and had a B/P of 50.... your patient was probably septic and third spacing..so the CHF was a minor issue to be delt with later....And she was on CPAP? Not SIMV or A/C???? No pulmunologist? You did the best you could do...just chart chart chart to CYA...

[xigris79]

Why was his gas so bad? Would paralyzing him have helped? I usually shut propofol off completely in a hypotensive pt. Different hospitals have different theories about Levo, which I find strange. The last unit I worked on maxed Levo out at 25 mcg/min. The hosptial I am at now has no cap. I usually request another alpha agonist, vaso and neo especially if the HR is high you don't want to be running dopa.

[lifeLONGstudent]

[quote=CVICURN2003;2830132]I am sorry you had a bad night. I ahve had levo running at 100 ML/hr, Vasopressin at 30 ml hour (3x normal dose) and EPI at 100 ml hour


Why are you telling her the volumes instead of dose?.... so was your levo an 8mg in 250 bag or was it 64mg in 250ml? She asked how high you have titrated a pressor, not the ml/hr.

Sorry, I am not gripping at you... just making an observation.

To answer the original question: I had a patient not too long ago that was on 300 mcgs of Neo, 90 mcs of Levo (that was the DOCs set max, not our hospital policy max), 20mcg of Dopamine and 0.04 units/min Vasopressin. I started CRRT that night AFTER we went to CT (THAT was a fun trip!). Also had HCO3 gtt for a pH of 6.8.... Fentanyl and Versed for sedation (intubated). After 3 weeks in MICU, pt was on weaning trials, successfully extubated and moved out to the floor. I didn't think she would live through the night.... neither did the docs. Makes me think twice about ever deciding to withdraw on anyone in my family.

If your patient is hypotensive, propofol is not an appropriate sedation agent.... and do you really get patients comfy on 20 mcs of propofol? It usually takes about 55-80 mcs of propofol for our patients to tolerate AC mode of ventilation. I don't think that you needed to paralyze the patient yet, just adequately sedate them. He wasn't oxygenating well because sounds like he was too awake for an obnoxious mode of ventilation (obnoxious if you are awake) -- he was bucking the vent.

Fentanyl causes less hypotension than Morphine, so I would ask for Fentanyl and Versed. Versed will cause some hypotension, so I would go heavy on the Fentanyl and light on the versed, depending on your pressures. If somone is opioid naive, you can sometimes just use Fentanyl to sedate them (we don't get too many of those pts where I work )

And you mentioned that you couldn't get an ABG. Titrating pressors on a patient without an art line is poor management to say it nicely..... this is a reflection on your physicians, not you. However, if you know it is wrong (or bad practice) and you go along with it.... that doesn't sit too well in court. Make sure you are charting defensively and have malpractice insurance (that YOU pay for, don't count on the hospital to take care of you)

You can only do so much with your hands tied behind your back, but I would consider changing employers.


LifeLONGstudent

[diveRN]

Had a septic pt a week ago or so... 90 of levo, 200 of neo, and 20 of dopamine ... and that was after several liters of fluid. Pt eventually expired.

While we were certainly doing what we could, it was mostly a dog and pony show. Lactate levels were rising and the pt was throwing out lots of ectopy as the family FINALLY made the decision to make the patient DNR.

Only once have I had someone on those dosages of those meds and had them pull through. Unfortunately, they expired a month later from ARF.

There's only so much we can do.

[poppy07]

Comments/Concerns:

most recently, propofol-- I would say 40-50 mcgs is more appropriate, unless you really want those guys knocked out!

Levo-- "therapeutic dose titrates up to 30"...after that it's debatable whether it really does anything, but why not go up. we had a pt on 200 of Levo.

This dr. you were in contact was a hospitalist? We don't really work with them, but my guess is they are generalists trained a little in each area, right? what is the chain of command there? if that's comparable to calling an intern or 2nd year, and not getting the desired response/orders...I'd go up the chain of command. For this pt to only be on dopamine and Levo is quite ridiculous. There are many other pressors available. I, too, would have suggested dobutamine (potent inotropic effect, less chronotropic effect), vaso (continuous rate of 0.04 units/min: NO TITRATING), Neo (initially titrate 100-180 to get that B/P up!!!). Also, was the rhythm just sinus tach? Or some other arrhythmia issues we needed to deal with? Also, having that A-line is nice...quick blood draws and ABG's. What's the pH? Maybe check an ionized Calcium, and give some Calcium.

My thoughts, but it sounds like you definitely had a tough night! It really makes it difficult when those doctors don't respond the way we'd like them to! Keep it up : )

[ghillbert]

A few of my thoughts - first of all, sounds like you were not very well supported by your senior nurses!!

If the patient had CCF, they most likely needed a LOT more fluid than 2-3L in 12 hrs (due to the poor starling response in heart failure patients). I definitely would have added a different pressor like vasopressin, or even an inotrope such as epinephrine.

I would have liked an art line, a central line and most likely, a swan for hemodynamic management.

Sounds like the patient was crashing and burning with cardiogenic shock to me. Unfortunately, adding more and more norepinephrine to get a BP is the worst thing to do - it increases the LV afterload and makes the myocardial oxygen consumption worse, which exacerbates the heart failure.

Sounds like the patient needed an IABP early and potentially an LVAD before crashing that badly.

Try not to second guess yourself, but if you get a chance to ask the doc what his rationales were for your learning experience, it would be worth it.