How high have you titrated levophed?

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.

Our max per policy is 100mcg/min. If we need more we just write an order and increase the max dosage. Routine use levoped 40-100mcg/min in some patients. I'm in a busy level 1 trauma ICU as well. It's always been interesting how different provider groups will manage the same patient in two opposite directions.

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.

Our max per policy is 100mcg/min. If we need more we just write an order and increase the max dosage. Routine use levoped 40-100mcg/min in some patients. I'm in a busy level 1 trauma ICU as well. It's always been interesting how different provider groups will manage the same patient in two opposite directions.

I'm only new in ICU myself and have never had an experience like yours. It sounds like you did all the right things, and you seem like an excellent ICU nurse.

The only thing I questioned was the fluid - only 2.5L in 12 hours, or 2.5L during the code? If it was over 12 hours, I wonder whether some fluid resus might have filled the tank, so to speak, giving you more to play with to achieve a higher systolic.

As to levophed, the highest rate I have seen so far is 32ml/hr of quad strength, which is 8mg in 50mL.