How high have you titrated levophed?

There are so so so so many things wrong with this. Was anyone helping you at all? Anyone with any experience would've been able to assist you. A high dose of levo is the least of the problem.

Is "through the roof" a valid response to this question?
We go as high as we have to with levo. We add vasopressin empirically at a rate of 0.04 units/min after we hit twenty mcgs on the levo. Other issues are addressed, of course---they're intubated, lined up, swanned (though less frequently than in the past), often end up on CVVHDF, and are the classic very sick ICU patient.
I have had massively septic patients on as high a rate as 200 (yes, two hundred--not a typo) mcgs/min and have had them live---and really live. Alive, extubated, kidneys working again. LOL---back to asking for another pillow and the remote for the TV. It's rather wonderful.
We almost never use neo except in immediately-post-surgical patients (anesthesiologists seem to love it) or patients who become hypotensive while receiving Interleukin 2 therapy (pressor of choice with those patients, according to our oncologists). We do levo first, add vaso, then epi if we need a third pressor. Rarely dopamine unless HR is also low---too arrythmogenic.
Sorry I don't have the time at the moment to read this whole thread so maybe I've just repeated what others have already said but I thought I'd toss this out as an "IME" post.

Racingmom4,
This was posted quite awhile ago. I just saw it due to new responders. I have to agree with PiPhi20004, there was alot more to question here than the max levo dose....
If you want to talk or clarify things, you can PM me.

I've had some patients who I've titrated up to only 18-20 mcg/min without any real change in pressure. I've also had patients where I've titrated up to 30 mcg/min and had increased pressures. It depends on the patient and what's going on. If all the receptors have already been hit then it's time to switch to a second pressor. Since we also run it in mcg/min instead of mcg/kg/min it's possible that higher doses could work in a larger patient (if my thinking is correct here...).

Oh, and don't even get me started on dopamine. I hate it...grr... why do so many people still use it as a pressor? Worthless, arrhythmia and tachycardia inducing drug... heh. Sure the pressure is higher, but the patient's heart rate is in the 140s. Remember Starling's curve? I want to say that so many times to people who start it as a pressor.

Yikes! That sounds like a rough day. However, where were the other nurses? Just two weeks ago I had a new post code with sbp in the 50s and I had another nurse (teamwork!) help me out with her. We wound up maxing her on levo, dopa, neo, vaso, and epi and still she was tanking. What the older nurses have always drove home with me is to give enough fluids with the pressors. In other words, the pressors won't work well enough if there isn't enough to "press". And did you say that the pt was on cpap/ bipap and not tubed?? There seems to be a few loose ends missing that I don't think you were responsible for.

I've gone up to 100 a few times (they both ended up dying- that high you're just buying time for family to get there). We add vaso at a sepsis dose (0.04) generally if we're up around 50 of levo and not seeing any changes.

That's ICU for ya...you get a pt on 6 of levo and 4 of dobutamine and around 0300 you're down to 2 of dobutamine and 3 of levo and you think "Oh, man, I can wean these off by the end of the night, their pressure and cardiac output are great" and about oh, 0430 they start tanking. That's what you get for thinking!!!!

I've only been in the MICU since June and have seen Levo before, but it's usually very low doses (5-20 mcg) and they're off it by the end of my shift. The past few nights I had a septic patient who I admitted on 12 mcg and when I left yesterday she was on 35 (had it up to 48 at one pont) and 0.04 unit/min of vaso.

She got 8L of fluid in 2 days (4L NS, 4L LR because she was so acidotic). She went oliguric, CVP was in the 30's. Potassium was 5.9 and creatinine 3.7 up from 4.7/2.2 the morning prior when I admitted her.

I hope she makes it as she is A&Ox3 and was a really nice lady. I'm kinda excited to go back in and see how things went, if she got intubated or got dialyzed, etc. Her condition is/was very serious but it's interesting to see how sepsis really hits people and watch them the progress through the stages. I'm a physiology nerd and was hitting up UpToDate and playing around Google all night figuring out all my unanswered questions.

Had a patient on 320mcg/min of levo the other night when I walked in and got report.......CRAZY I tell you.

what was your patient's Crit? Did the patient possibly need some units of blood and more fluids? If not possibly a contractility issue and may have benefitted from doubutamine? I the ICU where I worked when there is a falling blood pressure we always started with preload, then afterload then contractility. So fluids first, then pressors, then dobutamine. If none of this worked then it must have just been the patient's time. Don't be so hard on yourself. You did all you could with the resources you had and I'm sure you learned a lot from this experience and will be a better critical care nurse for it.

It appears you did a fine job with a difficult situation. I have been in the ICU for about 2 years (still new if you ask me), but just this week actually had a pt on 80 of levophed and 160 of neo and having to dopler the bp. Full code, HR in 140-180s, trach-vent. Even with a manual, dopler BP of 60/30, pt was totally with it. Sounds like a similiar situation. You do what you can, update the docs as much as possible and then chart all calls with docs.

One thing I have come to notice is that a lot of the time in critical care we are just delaying the inevitable and when its the pt's time there is not much that can be done even with all of our advances in healthcare.