Hypotension protocol

KatieMI, BSN, MSN, RN · Mar 18, 2018

The fact is: there must not be such thing as "hypotension protocol". At all. Whatsoever. Under no circumstances.

"Hypotension" is too relative thing and it has too many possible causes to be managed under premise "one size fits most". My own normal working BP is 90/50, maybe less, with HR usually low 100th. I lost count of how many times I had to literally run AMA for my life because someone with accidental RN or MD after last name decided that these numbers alone justify every test, task and thing known to humankind to be done because "they satisfy criteria". I am also sick and tired of treating patients with known systolic CHF, ESRD, on 5+ hypotensives, etc. after they were given a liter or two bolus for "dehydration" and then tankload of Lasix for "elevated BNP".

Levophed is not "better" and not "worse" than dopamine, or vasopressine, or dobutamine, or any other pressor. They all work differently and therefore each of them has separate indications, contraindications, precautions and side effects. Study your pharm, pathophysiology and, first and foremost, know and access your patient. Then you will know what is the best choice in every clinical situation. Treat patient, not numbers, charts or monitor screen. Become a clinical expert and advocate for your patients if you see someone holding onto numbers for dear life instead of treating them. And, above it all, be a CLINICIAN, not a "task-oriented" protocol follower.

Sorry for not giving you what you want to hear. But it is for every single one of us, every single mouth, set of eyes and pair of hands to prevent substitution of various protocols for critical thinking. I am not against all protocol and guideline but hanging Levophed or dopamine on everybody whose BP is 90/50 or below doesn't matter why and what is just as "intelligent" and safe as bloodletting everyone first thing, like it was done 500 years ago.

brownbook · Mar 18, 2018

The fact is: there must not be such thing as "hypotension protocol". At all. Whatsoever. Under no circumstances.
"Hypotension" is too relative thing and it has too many possible causes to be managed under premise "one size fits most". My own normal working BP is 90/50, maybe less, with HR usually low 100th. I lost count of how many times I had to literally run AMA for my life because someone with accidental RN or MD after last name decided that these numbers alone justify every test, task and thing known to humankind to be done because "they satisfy criteria". I am also sick and tired of treating patients with known systolic CHF, ESRD, on 5+ hypotensives, etc. after they were given a liter or two bolus for "dehydration" and then tankload of Lasix for "elevated BNP".
Levophed is not "better" and not "worse" than dopamine, or vasopressine, or dobutamine, or any other pressor. They all work differently and therefore each of them has separate indications, contraindications, precautions and side effects. Study your pharm, pathophysiology and, first and foremost, know and access your patient. Then you will know what is the best choice in every clinical situation. Treat patient, not numbers, charts or monitor screen. Become a clinical expert and advocate for your patients if you see someone holding onto numbers for dear life instead of treating them. And, above it all, be a CLINICIAN, not a "task-oriented" protocol follower.
Sorry for not giving you what you want to hear. But it is for every single one of us, every single mouth, set of eyes and pair of hands to prevent substitution of various protocols for critical thinking. I am not against all protocol and guideline but hanging Levophed or dopamine on everybody whose BP is 90/50 or below doesn't matter why and what is just as "intelligent" and safe as bloodletting everyone first thing, like it was done 500 years ago.

I think Allnurses should have a way to nominate responses for Best Answer of the Month award! Your response would get my vote! I can't think what the award would be except the satisfaction of knowing your fellow health care providers think you're great.

(I think we'd have to disqualify Davy Do from eligibility. He'd win every month.)

CharleeFoxtrot, BSN, RN · Mar 18, 2018

(I think we'd have to disqualify Davy Do from eligibility. He'd win every month.)

Just save time and have a "Davy Do" award of the month and another "Not Davy Do" award LOL

KatieMI, BSN, MSN, RN · Mar 18, 2018

Thank you, guys (blushing smiley)

Penelope_Pitstop, BSN, RN · Mar 19, 2018

Just save time and have a "Davy Do" award of the month and another "Not Davy Do" award LOL

A "Davey Do" and a "Davey Don't."

Triddin · Mar 19, 2018

We can use peripheral lines up to 10mcg/min for norepinephrine in our facility, but really, if the patient needs sustained norepinephrine, the doctor should be looking at inserting a central line. It should also be infusing in the largest vein you've got.

I would also be against a protocol low blood pressure. Really, you should be looking at all the patient data as what works for hypovolemic shock is different than distributive and such. We are trained to critically think.

LovingLife123 · Mar 19, 2018

First, there should be no "protocol" for hypotension. You have to look at the whole picture especially before starting pressors.

If our physicians decide pressors are appropriate, we almost always start with Levo unless contraindicated. Dopamine can cause heart arrhythmias.

Pressors should always go through a central line.

Davey Do · Mar 19, 2018

Thanks for the plugs and the kind words, but this is way out of my league.

One of the reasons I love this site is because I can learn so much from you all. AN.com and my medical wife Belinda helps to keep my head in the medical side of nursing.

Thanks again!

Davey Do · Mar 19, 2018

Thank you, guys (blushing smiley)

You deserve it, Katie. Your post was one good read!

My favorite part:

Study your pharm, pathophysiology and, first and foremost, know and access your patient. Then you will know what is the best choice in every clinical situation.

Belinda had a situation where she pressed an NP for more tests when both the NP and RT ruled a patient's symptoms were due to behavior, and a high lactic acid level was found.

I asked Belinda what made her go against these two professionals and she said, "They were looking at the lab results and I was looking at the patient".

Crush · Mar 19, 2018

I asked Belinda what made her go against these two professionals and she said, "They were looking at the lab results and I was looking at the patient".

Spot on. Got to look at everything, not just the numbers. And I loved Katie's response as well.

Rocknurse, MSN, APRN, NP · Mar 19, 2018

You can't really have an effective standard hypotension protocol because it all depends on the source of the hypotension. Is it volume depletion, bleeding, sepsis or a failing left ventricle that's causing the hypotension? You also couldn't have a standing protocol that chooses just one med because it might not be appropriate for that patient. For example, if you have a patient post MI who has a hypokinetic anterior wall, perhaps you want a little inotropy to improve their cardiac output, but if they're in failure and you give them inotropes, you're just increasing their myocardial oxygen demand and creating more problems. Dopamine has chronotropic and inotropic effects on the myocardium which increases heart rate and cardiac contractility. Some patients cannot tolerate that increase in heart rate. Levophed is mostly a alpha-adrenergic agonist and is useful in septic patients who need that extra squeeze. One size doesn't fit all. The patient might just need some fluid and none of these meds at all.

If a patient needs Levophed then they should really be in the ICU with a central line and on the monitor. Giving that peripherally is not advised due to the possibility of causing necrosis in the event of extravasation. I have however, seen Dopamine given peripherally, but again, I wouldn't be terribly comfortable with it.