How high have you titrated levophed?

Just a thought, in response to someone that isn't responsive to pressors or fluids, sometimes you may want to check their cortisol level. It is easily fixed, but if someone is in circulatory failure from or complicated by a critically low cortisol it seems NOTHING helps the BP until this is fixed...Seen this a few times. Good thing to check if your grappling. Kind of a while your at it lab, eh?

This patient had no pressure that is why you had no output MD said no to Neo and if you kept on giving fluid boluses he would have drown in fluid. After 30 mcg I don't know if it would have done anything for this Pt. I have titrated all my pressors to extremly high doses but it was only to keep a pressure long enough for family to say goodbye.
You could try calling pulmonoligist next time if patient is intubated. It is really sad that you don't have an attending to call. In any case you did a good job "R is for resusitation not resurection"

Are you saying that after your levo was at 30mcg you wouldn't have done anything else for this patient? Don't let your experiences cloud your judgement in patient management. You might be surprised at which patients do turn around and survive and which ones don't.

I learned long ago not to count my ICU chickens before they hatched.
I have had patients on, CRRT, HFOV's, hyperbaric treatment for gangrene, and beyond-maxed-out drips numbering in the double digits (yes, all treatments at one time for these patients) who, against tremendous odds, pull through. Okay, not just "pull through"---they live well and prosper. They can survive, neurologically intact, although most have some residual physical issues. But they go on to have productive happy lives.
And then there are those who you think are well on the road to recovery who suddenly crash and burn beyond redemption for no apparent reason. The ones that have you thinking "what could we have done differently...?"
But to write someone off who is anuric and on 30 mcgs of levo?
Now that's just tossing in the towel before the round is anywhere near over.

No what I'm saying is Patient should have been vented, lined, and have an MD there trying to turn this patient around a nurse should NOT have to do this over the phone with a HOSPITALIST! I would have gone to charge RN and asked to try to get an MD other than hospitalist to help. I have been many times in this situation but when it gets this bad especially with a person that could have a chance to pull through you can bet that the charge nurse gets on the phone and gets an MD to come in and stabilize the patient the RN can have all the best intentions in the world but without an order from the MD you can't do much. I am very nice to the MDs but they know that I push very hard when the patients are crashing. Things that I would have done until Md comes in is if ABGs were bad work with RT to see if we could ventilate patient better, Call Md and ask for another vasopressor so he did not want Neo than what? because I would not let him off the hook. If he was septic he needed fluid resusitation, if he had CHF and no output you are in a lot of trouble. I would have to know his history, labs ect. I have titrated levophen high enough to give a zombie a blood pressure but you clamp the patient down. All I know is that the RN did the best she could I have had patients code have their chest craked open after hear surgery and be sitting in bed talking to me a week later, but I had an attending, the cardiac surgeon and two other nurses in there working together. When I worked night shift I too had nights when my patients were crashing and I played phone tag with every MD in charge of the patient and when I did not get a response I grabbed any MD in the unit I have even grabbed an ID MD and he helped me save my patient and it was not his patient he looked at everything and called hospitalist and made very strong suggestions.

If the fluids did not work then I would only titrated up to 30mcg/min then if does not work add another pressor such a vasopression, if that doesn't work add Neo-Synephrine if that does not work, dopamine then as a last resort and epinephrine drip.

You know when you have 2 vassopressors running max yes you could have added more but you need to look for the cause "why is he hypotensive" what is his H&H is he septic? If he is septic then he vasodilated and he needs fluid. You have terrible ABGs, you have no pressure, a bad pump, you have dopamine and levophed going and you gave a fluid bolus and nothing I think even if you added more vasopressors he would have died unless there was an underlying cause that could be fixed like bleeding but you were in a resusitative mode at that time an a MD should have been there.

250mcg/min levo, with 999 units/hr of vasopressin, both maxed out on pumps with rates of 999ml/hr. packed cells i dont remember how many units in 2 differnt lines using trauma tubing running in each unit wide open. Obviously pt died, it was a AAA that came in disecting and we opened it at bedside, it was a blood bath. bad situation.

I had a hot mess of a patient last night.

Coded on the GPU, aspirated, was intubated. Had a pressure of 90/50 on the floor on 20 of Levo.

Came up to me, we placed an art line and his first pressure was 60/40. Cranked in 3L of fluid and by the time I left he was on 140 of Levo and 150 of Neo and his BP wasn't going above 80/40. He had a PO2 of 47 and a pH of 7.09 on 100% with 15 of PEEP. I threw the day nurse an amp of bicarb after the doc said it was a good call and headed out of that mess.

There was talk of nimbexing him but I think the family wanted to withdrawal care.

I'm glad I had that patient though, it's probably a fair guess he won't make it through but it reinforced a lot of the ins and outs of crashing patients for me.

I am sitting here in wonder and amazement after reading everyone's post...I have been an ICU nurse for ten years in a Level one trauma center, and I have to confess I had never seen anybody on 150-300 mcg of Levophed!!! At my facility the max is 20 per policy, and if that is ineffective, the consideration of other pressors need to be evaluated. I just hope that everyone is making sure to have an written order somewhere when a physician request those out of range dosages. Remember you all worked hard for your licenses.