How high have you titrated levophed?

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.

What I want to know, is why the hell was the patient on CPAP? Good grief. The patient should be sedated and on CMV settings. Was there a resident in the unit with you? A doctor should have been present. That whole situation would not fly with me. If my patient is crumping that better damn sure be a doctor at the bedside with me. None of this calling back and forth crap.

I agree. After 20 mcg/min of Levophed, you're probably not going to get much more of a response from increasing the dose. You did well to keep putting the onus back on the doctor for the low pressures. 2nd guessing yourself, in my experience, is usually counterproductive. Assuming an adequate CVP, perhaps you could have titrated the Dopamine up to 20 mcg/kg/min, but adding an additional pressor like vasopressin is perhaps the most you could hope to get out of that doctor. I'm not sure what his Hx was and the cause of the CHF, but I don't think flooding him with fluid was the answer. The amount given sounds about right. With that much Levophed, the problem is clearly not that his arteries are not clamped down enough. Had anyone suggested an inotrope such as Dobutamine to try to increase stroke volume and thus increase cardiac output? Again, it sounds like you did a good job. All we can ask of ourselves is to do the best we can. If we do that, we have nothing to be ashamed of.