Dopamine infused by infusion pumps

[laurentm38]

Hi everybody !

I was wondering if someone could tell me how dopamine is usually infused in the USA, more precisely in ICU.

I was told it is usually prepared in bags and infused with infusion pumps, which sounds quite surprising to me, as in Europe it is prepared in syringes and infused with syringe pumps.

How is the dopamine prepared ? which mass ? in which volume ?

What are the flow rates of infusion ?

Do you manage to keep the BP constant ?

This is interesting to me, as the change of syringes is a "sensitive" time and requieres much attention, due to the short half life of this drug.

Maybe we could take some inspiration from the US medical practice...

Thanks for responses...

Laurent, from France

[Skejnurse]

Hi Laurent

Thought you might want some input from somewhere else than the US. I work at an ICU in Denmark we do it somewhat different. We use what we call the six rule. You take the patients weight (in kg) at multiply by 6 that gives the total mg which you mix with isotonic glukose up to a total volume of 100 ml.

That results in: 1 ml = 1 mcg/kg/min

The same goes for dobutamine. Adrenalin is mixed by multiplying with 0.06 giving af dose where 1 ml = 0.01 mcg/kg/min.

It is infused using syringe infusion pumps.

[lilrn03]

We get dopamine drips on my combined PEDS/Medsurg floor, but only at a renal rate which I believe is 2-4 mcg/kg.

I was pulled to another floor last night and had one infiltrate. I hope I NEVER have to deal with that again.

Sorry, but pressors never belong on a med-surg floor. Sure they have continuous BP monitoring, but who is in the room or close by watching it?

Dopapmine and Doputamine do not belong an M/S units at all. How about telemetry monitoring that goes along with the continuous BP monitoring? How ofter are the BPs being taken?

BP needs to be charted at least every one hour for pressors if the dose is not being titrated, and at least every fifteen minutes for doeses that are being titrated. With a full load of patients, this is too much of a high acuity patient to have on the nurisng unit of that type.

[Mags4711, RN]

Hi Laurent

Thought you might want some input from somewhere else than the US. I work at an ICU in Denmark we do it somewhat different. We use what we call the six rule. You take the patients weight (in kg) at multiply by 6 that gives the total mg which you mix with isotonic glukose up to a total volume of 100 ml.

That results in: 1 ml = 1 mcg/kg/min

The same goes for dobutamine. Adrenalin is mixed by multiplying with 0.06 giving af dose where 1 ml = 0.01 mcg/kg/min.

It is infused using syringe infusion pumps.

I currently work in a NICU, and we have just done away with the "Rule of Six" about four months ago and have gone to standard concentrations. We also just get new syringe pumps that do the calculations for us (of course we double check them).

I have always liked the "Rule of Six" but it does have it's drawbacks, it is more costly considering every bag/syringe must be mixed by hand, and you have to be very careful that if the patient's weight changes over time and they are on vasoactive drips for a while, that you get the drips rewritten to reflect the changes. One of the other drawbacks is the rate at which you have to run the drip if you have someone who is requiring high doses of a drip. If you have a patient who should be fluid restricted, and you have dopamine at 20/hr=20mcg/kg and dobutamine at 20/hr=20mcg/kg, then you are already at 40cc/hr. What about nutrition or other necessary drips? In those cases, we have "double" or "quadruple" concentrated them.

When I work adult ICU we also use the 800/250 (probably 5:1 over the 400/250) dopamine. Again, only in central lines, but if they are on a pressor, they've got a CVL or a Swan almost always.

[Mags4711, RN]

Hi, Laurent. Like the other posters, we generally hang dopamine in a pre-mixed bag. Pts will usually come back from surgery with syringe pumps (anesthesiology refuses to use pumps). We will usually leave them on until the pt is stable, and we're sure they won't be going back to surgery - otherwise we'll have to change them all back to syringes. I hear you about the "sensitive" time during the change of syringes. That's why I hate them with such a passion - my pressures always drop no matter how fast I can get the darn thing changed. Bags on pumps are the way to go - you don't have to stop the infusion to change bags.

For years I have agreed with your view about bags on pumps versus syringe pumps, until about five months ago. I have done adult, peds and now NICU and let me tell you, the most sensitive to pauses in vasoactive drips are the NICU kiddos. Well we just bought new MedFusion 3500 syringe pumps and they are great for this, they have "FlowSentry" and it automatically adjusts to back down the pressure post occlusion so the patient does not get a bolus. And if you change a syringe, you can hit a button and it sort of "tightens" up the plunger so that there is no loss in infusion rate. Pretty cool pump, big, but it also has pharmacy software that is amazing!

[neoicu2684]

Help! I am a new NICU nurse. Whenever I hang IV dopamine I always end up giving the patient an unintentional bolus when I am changing their IV bag for the night. I was told not to use the roller clamp because it can give them a bolus. But I feel like once you unclamp the tubing, it will give the baby bolus anyway. Does anyone have a special technique they use when they are hanging their dopamine that will prevent the babies from getting a bolus? Thanks!

[Darkfield]

We send our post cabgs out to the floor with Dopamine gtts at low dose (3 mcgs). At first I was surprised and kind of worried about this too. However, we haven't had any bad events, the floor nurses don't titrate the dopamine. My concern, since we make sure the pts are stable in the unit for a while with us not titrating it before they go to floor, was more that we always have central line access, but it is d/c'd before the pt goes out. The nurses run dopamine through peripherals on the floor, which is not the ideal way to infuse it. With their pt load, they can't check IV sites as frequently as we do in the unit, but so far we haven't heard anything negative about it.

I can't imagine ever ever running a drip like this on my old med surg floor. I may have had insulin twice and a lasix drip; otherwise the only thing resembling a drip was a pca. And why would a line be dc'd with a pt still on a drip, especially one that is as terrible as dopamine? If the pt still needs dopmine, isn't there a chance that they're unstable enough to need another pressor or iatrogenic? Back in goes the line. What kind of a floor is it where the nurses can manage a critical drip but not central access? I'm sorry, but this sounds like an enourmous train wreck waiting to happen.

[Darkfield]

The problem with dopa as a pressor is that you have to turn the dose up so high to get any rise in BP, which then results in tachycardia, so then you have to switch to Levophed anyway.

Just have to reply to this as well; the pressor you use has a lot to do with why you are using the pressor. If the pt is septic, for example, you'll want levophed because it constricts the periphery and increases flow to the central organs. Dopamine has a more inotrophic effect, but it causes far more arrhytmias than levo. I see it more in pts with a cardiac etiology than anything. I've seen pts for whom levo was not enough, and I've seen patients go hypotensive because of levo.

Off topic, but so many of our pts that come from outside hospitals get to us septic with dopamine running, because the providers are still following the mantra, "levophed, leave'em dead,".