How high have you titrated levophed?

Well, recently had a 19yr old male who coded on the floor post-op for a bowel resection. Previously healthy guy. We saved him, brought to ICU tubed, lined etc. Started Levo, added vasopressin, dobutamine, epi, propofol. Over the course of a few days levo was at 80mcg along with all the other gtts. Kidneys shut down, was not looking good. 43 liters positive, fluid was the major factor in keeping MAP of 60 BP often 60/30. Long story short, he woke up, no deficits, renal function returned, pt went home.

In the facitility that I work in levafed is the last choice of pressors. We are usually starting to max out on neo the starting to add the levo.
Checked at my facitlity to see what the max is levo 30 mcg's, neois 200 mcg's.
Our docs are pretty open to suggestions from us in AICU but we are a just a small unit. that may be the difference too.

Our facility runs Levophed at mcg/min, where many run at mcg/kg/min. The highest I have ever titrated Levophed was beyond our formulary max of 300 mcg/min. (My Kathi White reference notebook says 30 mcg/min.) This particular patient was a "heroic efforts" scenario - a younger man (with 2 young children) who had arrested while swimming laps. He was on dopamine, dobutamine, neosynephrine, levophed, and epi. He was vented and on an IABP. From the point I got report, I knew the day would be a hectic one. I simply asked the intensivist "Do I stop at the formulary maxes, or go on to ridiculous levels?" His answer - "Do what you have to do to get his pressures up." I was beyond the max on every single drip at the end of my day. I think I was at 20 mcg/kg/min on both the dop & dob, 1500 mcg/min on the neo, 500 mcg/min on the levo, and 150 mcg/min on the epi. Night shift added vasopressin after his first PEA code. His family let him go with the second code.

I've run pressors higher than "max", usually have the doc right an order stating something like "titrate above xyz as needed", or something to that effect so that there's a record that they knew it was high and were okay with what we were doing. I have a question about something the original poster wrote:

"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."

Any RNs out there who have ever thought it was ok to pull a tube??? I'm a fairly new nurse and I would NEVER even dream of dreaming about pulling an ETT. I think it would be something like assisted suicide unless there is an order to withdraw ALL care on the pt. And even then, in my facility anyways, an RN would not do it. Maybe respiratory. . . maybe. Also, if pt was spitting up blood or anything from tube I think it might be less traumatic to leave it in place as tube removal would mean more risk for full blown aspiration. . . although at the stage mentioned it wouldn't really be an issue I guess? just a little confused about the tube pulling thing.

But to the original poster, sometimes you can do everything and more and pt's still die. Don't feel bad or that you did something wrong. Some times this job just stinks.

The highest I have ran Levophed is 250 ml/hr of quad-strength ( 32mg/250ml). I don't believe there is a "max" rate, you should titrate to effect but my experience has been is anything over 100ml/hr of regular concentration (8mg/250ml) for longer than a few hours is just flogging the patient..

before anything else, first thing to do when BP crashing is to--TURN OFF DIPRIVAN. right now the pt gagging on the ET tube isnt your priority--the BP is. you're turning up the propofol and turning up the pressors--youre see-sawing the pt.

1. this was an emergency yes? if so it must be treated like one. i dont think there is time to insert an IABP while the pt is crashing. your thinking and thus the flow of interventions should follow this train of thought. if the pressure was in the 40s this is a code (at least i would have treated it as one) especially in that you were doing everything and nothing was working and the trend is going down real fast.

2. secondly, time wasted on calling people back and forth--again, in a code, cant do this. need to get the crash cart, call for help, get your charge nurse/supervisor, and get ACLS protocol. it is better to call a code and be wrong and get embarrassed by looking stupid than to try to do things all by yourself and kill a pt (not insinuating you did, just making a point).

3. first thing i would have done was give fluid bolus. one of the basic things to treat a crashing bp. get NS and open it all the way or if on a pump set rate at 999.

4. next thing was of course titrate his pressors. highest levo for us here in SICU is around 80 (some have gone up to 100). we would also have hung neo (as high as 180).

5. the priority at this point would have been to save the pt and thus, treat his emergency sx--crashing bp. all the other stuff--fluid overload, low urine output, etc...are secondary and should have been attended to AFTER THE PT CRASHING RESOLVES.

6. if youre going to call a code, then you can get some EPI in and see how that works. also, NaHCO3 sometimes help--i have seen a doctor order 3 amps for crashing bp. next thing would be calcium chloride--1amp--which helps with the myocardial membrane ionization.

7. last stuff to check--what are the H/H? he probably needs blood, or he was probably bleeding somewhere. what are the electrolytes?



at the end of the day, pat yourself on the back because you did what you were able to do and tried to save the pt. you cared for the patient and that's worth more than any accolade. like others have said, you need to learn to let go. you need to learn to leave work at work. you cannot save everyone but you have the right mentality to TRY TO save everyone.

you did a good job. learn from it and get better. all you can really do.

WowZAAA!

Did increasing the gtts beyond their max actually increase his BP?

When you crank up your pressors like that they usually start to lose affect quicker and quicker. I've found myself going up by 10-20mcg/min of Levo. You will see an initial effect but the effect lasts only a short period of time then you are turning it up again, and over a few hours the effect gets shorter and shorter. Basically you're just buying time for the family to either arrive or accept the fact that their family member isn't going to make it.

Never be afraid to "suggest" adding another pressor. But my best advice is know your facilities policy on levo. Most places the max is 30 mcg . I have titrated up to 40....but I didnt do that till the MD physcially wrote the order and I had faxed it to pharmacy. This was just a scenario where we were keeping them alive till family arrived to pull the plug, They were also maxed out on 3 other pressors. But again...my advice is know you units policy on that drug.,...if the doc wants you to exceed that they need to come in and physcially write that order. So....know your policy on your max doseage

Well. That works if you have a inotrope/pressor that you haven't added or tried already.... lol