[poppy07]

I had a pt last 2 days, septic shock, 1 wk s/p c-section, ARF, ARDS, HR 150's (previous day 160's to 170), on Vaso and Levo. Which would you have weaned first and why?

[nurseabc123]

Originally Posted by poppy07

I had a pt last 2 days, septic shock, 1 wk s/p c-section, ARF, ARDS, HR 150's (previous day 160's to 170), on Vaso and Levo. Which would you have weaned first and why?

Were you maxed out on your levo?

MD's preference?

Any hemodynamics- CO/CI/SVR/SVRI?

Hard to say with such little information.

[poppy07]

MD's wanted pt weaned from pressors as much as possible before surgery...allowed me to decide whichever first... I started weaning off Levo...running 20 mcg/min, vaso running 2.4 units/hr, nimbex, versed gtt (key items running).

monitoring the map...it was 70's to 80's before weaning down. docs wanted map maintained 60 min (ideal 65+)

HR in 150's

pt had cvp~ 12-15
no swan

[fedewa0627]

In my experience our physician prefer to wean the vasopressin before levophed. Often it is up to the physician because vasopressing is still in it's infancy of being understood. At my facility vasopressin is either on or off, no titration. Levophed is ofter titrated and is much easier to see a direct cause and effect relationship on b/p with dose changes.

[CVICURN2003]

Depends on what the patient is in for GI MD's hate LEVO (kills their gut surgeries). We wean off levo first...Even on our CABG patients. We don't use vasopressin that much on our CABG pts. We just max out every other drug on the market if we need too

[cardiacRN2006]

In septic shock, levo would be the last one I'd wean...

[Artemis2]

You know, they are both such potent pressors I'm not sure it makes a difference which one goes first. I will be interested to see what everyone else says. Personally I think I would wean the vaso first just because I have worked with levo longer and am more comfortable and familiar with it.

[suanna]

Im old and getting a bit forgetful but levo and vasoperssin work on different receptors. Where I work we only go to vasopressin as a last resort but against septic shock it is at times much more effective than levo. I would wean the levophed first in that it may be doing very little. Good chance you can get it all the way off if your vaso is doing its job.

[RN1980]

we really don't have a policy for which to wean, we generaly go by the md's prefrence on which to start. in my exp. i just sort of have to tinker with the drugs alittle and maybe you'll be able to see some subtle changes in the pressures (if you got a swanz you may see some small changes in your numbers) now trying to find the right dosage for the patients when your own 2 pressor type drugs esp. levo and vaso can be alittle tryiong and time consumming. but like i said we ask the doc, if he wont give a straight answer we just start backing off while looking at the numbers and the patient. like i said it can be a slow process, it has taken me hrs just to drop a few mcgs of levo and aunit or 2 of vaso, cause you very well may have to go back up on one and down on the other and vice-versa.

[classicaldreams]

Originally Posted by poppy07

I had a pt last 2 days, septic shock, 1 wk s/p c-section, ARF, ARDS, HR 150's (previous day 160's to 170), on Vaso and Levo. Which would you have weaned first and why?

Hi,

Where I work, we don't wean vasopressin up or down but always run it at 0.04 units/hr. Based on our yet-to-be-approved protocol for septic patients, I would start vasopressin if I needed to infuse levophed at >10 mcg/min. I would then wean the patient doing the opposite. (Wean Levophed down to 10 mcg/min then turn the vasopressin off and continue to wean the levophed to off.) In your case, though, I would be concerned about the HR in the 150s. Is patient in pain, a reaction to the Levophed, high amount of peep, or are they still so septic?

Classicdreams