[racing-mom4]

Just out of curiosity---how high have you titrated levophed before? History, pt in with serious health history, admitted with CHF. Coded on the floor. CPR alone brings back a rhythem I come in at 7pm to find her on cpap with an et tube placed. levophed at 30, dopamine at 5, heparin at 9 and propofonal at 20. We attempt ABGs and are unsuccesful, fighting the tube and restraints, increase the propofnal and attempt art line and picc line. Succesful. B/P systolic in the 70s heart rates in the 140s. I cant go too high on the dopamine due to the heart rate, titrate up and down and can not find a balance. I take the dopamine up to 10mcg at one point. Dr insists verbally over the phone I keep titrating the levophed to get bp systolic at the 100 range. Can not be done, I call pharmacy to question just how high I can go, am told there really is no cap?? according to my drug book 30 is range. Eventually pt put on vent, lower the propofonal to try and raise bp. I eventually titrate the levophed up to 60!!! I am so uncomfortable at the 60 range I call the Dr almost in tears--told him I feel like I am treading water and not keeping my head above. FYI I called him when I hit 50 and still had systolic in the 60s. I had the pumps concurrent with 75ns behind the dopamine and levophed. These are running into her picc.
No output in over 12 hours even though almost 2.5 liters of fluids/meds combined in. Dr made aware of I&O. Only order a small dose of Lasix. Not successful. ABG's horrible! FYI patient full code and family even after 3 in depth conversations insists on full code status. I am literally going over my algorithms in the supply room in preparation. Dr tells me to tell the family this is it, this is as high as the drips can go. Pt is 38 yr old. Finally family agrees to no code status, but want to remain where we are at, leave the et tube in and leave the drips where at, but understand we will not be giving any more meds.

The patient passed away shortly after the end of my shift, I was still on the unit so I assisted. Very sad, I felt so frustrated like I should have done something but totally felt like my hands were tied. Plus just didnt know what to do anyways---I was in contact with the ER doc and he had her tele up in er so he could watch. I had contacted primary and heart dr several times through out night. There is something really freaky about seeing an art line bp of 48/43 and a heart rate of 120.

I dont really even know what I am asking for in this post---I feel like I did something wrong, like I should have been doing more, or maybe did too much with the levophed that high. BUt i just didnt know what else to do, So all you critical care nurses, feel free to educate me. I am a new ICU nurse. The learning curve is huge. I had the nursing supervisor on my back most of the night, she said i did fine but I still feel like there was something else I should have suggested to the Drs.

[bethem]

I'm only new in ICU myself and have never had an experience like yours. It sounds like you did all the right things, and you seem like an excellent ICU nurse.

The only thing I questioned was the fluid - only 2.5L in 12 hours, or 2.5L during the code? If it was over 12 hours, I wonder whether some fluid resus might have filled the tank, so to speak, giving you more to play with to achieve a higher systolic.

As to levophed, the highest rate I have seen so far is 32ml/hr of quad strength, which is 8mg in 50mL.

[racing-mom4]

The fluid in was almost 3 liters total in the course of 12 hours. I questioned the fluids going in, as nothing was coming out per say, the logic behind the fluids was one to push the meds in faster by running them concurrent with the 75ml hour each for the levophed and dopamine, then I was instructed at one time during the night, maybe 11ish to give a 250 bolus to try and get bp up.

I really like the ICU, but I was pretty freaked out last night....I just dont like that helpless feeling. I was very good at explaining every thing to the family to keep them in reality and on the same page, at one point one of the brothers said "suzy it is not working is it?" as I was titrating her meds.

Then to make it even worse---when the heart started plummeting and the one daughter was up in the bed with dying parent sobbing, and pt was vomiting bloody froth around et tube, I said to daughter "Do you want me to remove the et tube?" and she sobbed yes yes yes. Then the day nurse who I had just given report to told me I couldnt do that with out a Dr order, even though family insisted. So I swing open the curtain and ask another nurse, and she agrees,. cant remove the tube, so a call goes down to get the ER doc to give the order to remove, by the time the order comes, the pt has already passed. So I felt like crap,. make an offer to remove the tube only to find out I cant.

I just feel like I got hit by a bus. I dont think I will sleep today, I think I am going to run the events through my mind over and over.

[cardiacRN2006]

When I reach the 20mcg mark I start advocating for another presser. If the Dr doesn't like Dopamine then I'd add Neo or ask for vasopressin.

[hikergurl24]

I would ask what your CVP was, I'm assuming you had a central line for pressors...?? Vasopressin or Neo would have been my next bet for sure, and I would have demanded the the MD to come to the bedside...its so hard when you are playing phone tag with a crashing patient. Just another thought, I would have tried to get rid of the propofol and switched to whatever your institution uses for sedation/pain control like versed/fentanyl. They also cause the BP to decrease, however it might have helped the hypotension a smidgen, although it seemed that this patient was not going to survive.

The other thing to remember is, you are not going to save every patient, and you are going to get patients that you are not going to be able to manage the way you want or you feel is the best. It doesn't matter if you are a new nurse or not. Deep breaths, you will see it again, you will feel the same way. The only thing that changes is your ability to leave it at work. Your screen name is racing mom. Go home and hold your kids, it helps.

[racing-mom4]

I dont remember what the CVP was...I did call that in to the Dr around midnight but for the life of me I am not remembering what the reading was,I did ask Dr about the neo as that was what the pharmacist recommended when I called him. He said no to the Neo I didnt question him on why. Dr was a hospitilist and we have had trouble before getting them in house. In fact cardiologist told me he was not going to manage this patient over the phone and to deal with the hospitilist--so that is who I was calling through out night, I did call cardiology one more time thought to report the ABG report.

Thanks for your kind words---it was a long night, I know she was in critical condition and was not going to walk out of the hospital. The family knew she was sick with and extensive medical history, I just dont think they were prepared to lose her this hospital stay.

There is nothing that could have prepared me for hearing her mother and daughter wail/sob over her body.

[ukstudent]

I don't work in a MICU, we do things a little different in the SICU. To answer your question on how high have I seen levophed titrated. I have seen 250 mcg. Personally I have gone to 150 mcg's plus epi, plus vaso, plus dobut and if memory is correct a little dopamine.

[racing-mom4]

Originally Posted by ukstudent

I don't work in a MICU, we do things a little different in the SICU. To answer your question on how high have I seen levophed titrated. I have seen 250 mcg. Personally I have gone to 150 mcg's plus epi, plus vaso, plus dobut and if memory is correct a little dopamine.

WOW---OK so that is amazing!!!

[snoslicer8]

I've seen as much as 150mcg/min in my SICU, along with many other pressers/contractility agents in use.

[Diary/Dairy]

Couple of things.

Last ABG - Levophed works better in a ph neutral environment - so you will probably need a bicarb bolus and then gtt.

Highest levophed dose - I have given in the 200's - However, levophed is not really effective after 30 or so mcg.

I don't think the lasix was appropriate order either, given that your patient sounds shocky, probably in acute renal failure.

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.