LEVO or VASO--which to wean first?

  1. I had a pt last 2 days, septic shock, 1 wk s/p c-section, ARF, ARDS, HR 150's (previous day 160's to 170), on Vaso and Levo. Which would you have weaned first and why?
    •  
  2. 12 Comments

  3. by   nurseabc123
    Quote from poppy07
    I had a pt last 2 days, septic shock, 1 wk s/p c-section, ARF, ARDS, HR 150's (previous day 160's to 170), on Vaso and Levo. Which would you have weaned first and why?
    Were you maxed out on your levo?

    MD's preference?

    Any hemodynamics- CO/CI/SVR/SVRI?

    Hard to say with such little information.
  4. by   poppy07
    MD's wanted pt weaned from pressors as much as possible before surgery...allowed me to decide whichever first... I started weaning off Levo...running 20 mcg/min, vaso running 2.4 units/hr, nimbex, versed gtt (key items running).

    monitoring the map...it was 70's to 80's before weaning down. docs wanted map maintained 60 min (ideal 65+)

    HR in 150's

    pt had cvp~ 12-15
    no swan
  5. by   fedewa0627
    In my experience our physician prefer to wean the vasopressin before levophed. Often it is up to the physician because vasopressing is still in it's infancy of being understood. At my facility vasopressin is either on or off, no titration. Levophed is ofter titrated and is much easier to see a direct cause and effect relationship on b/p with dose changes.
  6. by   CVICURN2003
    Depends on what the patient is in for GI MD's hate LEVO (kills their gut surgeries). We wean off levo first...Even on our CABG patients. We don't use vasopressin that much on our CABG pts. We just max out every other drug on the market if we need too
  7. by   cardiacRN2006
    In septic shock, levo would be the last one I'd wean...
  8. by   Artemis2
    You know, they are both such potent pressors I'm not sure it makes a difference which one goes first. I will be interested to see what everyone else says. Personally I think I would wean the vaso first just because I have worked with levo longer and am more comfortable and familiar with it.
  9. by   suanna
    Im old and getting a bit forgetful but levo and vasoperssin work on different receptors. Where I work we only go to vasopressin as a last resort but against septic shock it is at times much more effective than levo. I would wean the levophed first in that it may be doing very little. Good chance you can get it all the way off if your vaso is doing its job.
  10. by   RN1980
    we really don't have a policy for which to wean, we generaly go by the md's prefrence on which to start. in my exp. i just sort of have to tinker with the drugs alittle and maybe you'll be able to see some subtle changes in the pressures (if you got a swanz you may see some small changes in your numbers) now trying to find the right dosage for the patients when your own 2 pressor type drugs esp. levo and vaso can be alittle tryiong and time consumming. but like i said we ask the doc, if he wont give a straight answer we just start backing off while looking at the numbers and the patient. like i said it can be a slow process, it has taken me hrs just to drop a few mcgs of levo and aunit or 2 of vaso, cause you very well may have to go back up on one and down on the other and vice-versa.
  11. by   classicaldreams
    Quote from poppy07
    I had a pt last 2 days, septic shock, 1 wk s/p c-section, ARF, ARDS, HR 150's (previous day 160's to 170), on Vaso and Levo. Which would you have weaned first and why?

    Hi,

    Where I work, we don't wean vasopressin up or down but always run it at 0.04 units/hr. Based on our yet-to-be-approved protocol for septic patients, I would start vasopressin if I needed to infuse levophed at >10 mcg/min. I would then wean the patient doing the opposite. (Wean Levophed down to 10 mcg/min then turn the vasopressin off and continue to wean the levophed to off.) In your case, though, I would be concerned about the HR in the 150s. Is patient in pain, a reaction to the Levophed, high amount of peep, or are they still so septic?

    Classicdreams
  12. by   pietr422
    I am a nursing student with 5 weeks to go until graduation. I just finished my senior practicum in the ICU, during which I had a septic patient with severe septic shock. This patient was on levo and vaso, and my preceptor and I were trying to wean the vaso first per the MD order. As we decreased the vaso which was originally running at 0.04 units/hr, we found that the patient's pressures would not tolerate the decrease, so we titrated the levo up to compensate, which was minimally effective. After fussing around for quite some time, we put the patient back on the 0.04 units/hr of vaso and returned the levo to its original rate.

    Anyway... I found an interesting article titled about the topic of pressors and septic shock. I would definately recommend it as it is worth the read and explains how each of these pressors works to manage hypovolemia secondary to septic shock.

    Anyway, based on this article, I would wean the vasopressin first.



    http://ccn.aacnjournals.org/cgi/content/full/26/6/17





    -Andy
  13. by   VandyNurse714
    We don't titrate vaso in our unit, either. It is also running at 0.04 units/hr. I would ask the doctor at what point would he or she prefer turning the vaso off. I feel more comfortable with levo, so I would rather get the vaso weaned completely off (while simultaneously weaning levo bit by bit) then coming down solely on the levo. I would venture to say that patient would tolerate weaning something at this point with MAP in the 70s and 80s, CVP 12-15, and HR in 150s. That HR concerns me as well.
  14. by   yeSICU
    I personally always like to get rid of Levo ASAP... Something about the whole "Leave em dead" rhyme gets me all antsy. We run Vaso at a standard rate. We call it "Shock dose Vaso". I love vaso because you don't get the peripheral clamp down, aka your pt. keeps their toes and finger tips. Docs seem to think the same way, as far as rationale pharmacologically speaking, I will have to get back with you on that.
    Last edit by yeSICU on Nov 8, '07

close