Question about titrating pressors

dorimar, BSN, RN · Apr 30, 2006

I'm not sure what you mean by fast. I always evaluate how the patient responds to my titration and titrate accordingly. I will usually start by coming down 0.5 mcg's at a time. if this is too much i decrease it to .25 mcg's at a time. If he was hypertensive (believe me i've walked in and found my patient with SB 170 and on levo and not for SAH to prevent vasospasms in which they use levo to keep it that high), then i will go down faster, but I always evaluate how my patient responds. If he is just at his paramaters, i am not in any hurry to wean. Say his order is to keep SBP 90 and his sbp is 100, well I am in no hurry- I think my levo is doing a dandy job just where it is. But if my sbp is 120 i will come down .25 to .5 mcgs and evaluate. in 20 min if he is still 120 i might come down the same amount, but if he dropped to 100 systolic i go much slower and may not come down again for another hour if he creeps back up to 120ish range again. Aslo if i notice a drop in u/o with weaning- after bp drops (even if it is with in ordered parameters) i won't be in a hurry to wean. I've seen patients drop u/o if sbp goses from 100 to say 90 . Of course i know that levo is bad for kidney perfusion, but sometimes it is good for kidney perfusion as well. I prefer MAP for parameters instead of SBP. Interestingly enough, in some of my patietns i also notice a drop in O2 saturations in relation to lower bp (and not because it is not perfusing or picking up pleth, I mean with a good wave form and confimred with abg). If this is the case i don't push it either.

kat911 · May 1, 2006

I always preferred slow titration off of pressors. If you go too fast they can bottom out, goal is to keep them stable, Only thing I go faster on is nipride and nitroglycerine because they have such short term affects. You need to go with what you feel comfortable with and don't get in too much of a hurry if the patient is stable.

Artemis2 · May 4, 2006

A lot of people are afraid of Levophed. Have you ever heard the expression, "leave 'em dead Levophed"? Years ago Levo was only used as a drug of last resort in code situations. It is has made a comeback and is now used more routinely in the ICU... and that is a good thing. Used properly it is a great drug because its effect is pure pressor without any cardiac effects like you would see in drugs like dopamine. That said, here are a few things I have learned about levo over the years. Dorimar makes some excellent points in her post.

It is always advisable to begin any wean slowly until you have an understanding of how the patient will respond. One thing that the textbooks never talk about is your nursing instincts as an ICU nurse. Over the course of a 12 hour shift you have stood at that bedside, watching every fluctuation in heart rate, and BP. You have run your hands over their body countless times. You know this patient. Not just intellectually but instinctively so activate those instincts and lets wean.

First, how are your patient's pedal pulses? If they have decent pedals you can relax. If they are perfusing their pedals they are perfusing their kidneys and you can afford a nice slow wean. Second, how hydrated are they? You have to have something to fill that space as the vascular beds relax. With a patient who is dry you will have to wean slower and in smaller increments and you may not be able to get them weaned all the way off. You may need to have a conversation with the Doc about giving some albumin or increasing the IVF. (With all these steps of course you are taking into account cardiac function and kidney function. There are many variables but these are just some gross guidelines.) Third, how is your starting BP? Do you have a systolic of 100 or of 140? Again, this will play into how fast you can wean and what your chances of weaning all the way off are.

I wean differently than most nurses. While I am aware of the concentration of the drug (mcg/cc) I wean by drops. I pick a starting point, say 3 drops and wean. How did they handle it? Can I take a bigger step? Maybe in 15 minutes I will try 5 drops, then 8 drops. Ok, that was too much so I back off to 5 drops. Over the course of the first hour you, using your knowledge and instincts, will figure out how big a step you can take. Then take your time allowing the patient time to fill the vascular bed and compensate for the absence of the pressor. This is where albumin comes in handy as so many people are swollen and it helps you mobalize fluid from the third space into the vascular bed.

Monitoring your pedal pulses and unine output will help you trememdously in deciding how agressively you need to wean. If your feet are cold and pedals weak you will want to get the levo off as fast as the patient can tolerate but don't forget to fill the vascular bed to maintain your BP, cardiac output and UOP and avoid the rapid wean roller coaster.

And take note of what dorimar said...good stuff!

Good luck!

nursenary57 · May 5, 2006

Artemis,

That was a great post. Wish you had been my preceptor when I got out of school. You took a complex process and made it simple. Or as I like to say "You rednecked it down for us commoners." You titrate by drops? Sounds like you've been in this game for awhile!

I do have to disagree with one thing though: Levophed actually does have cardiac/inotropic effects. At lower infusion rates it has effects on beta-1 receptors, therefore causing increased cardiac contractility. I found this passage about Levophed on p.321-322 from Hemodynamic Monitoring: Invasive and Noninvasive Clinical Application by Gloria Oblouk Darovic:

"Norepinephrine is a catecholamine with predominant alpha-1 and some beta-1 adrenergic stimulation. Norepinephrine causes constriction of all systemic arterioles except those of the coronary and cerebral circulations and produces direct inotropic and chronotropic cardiac stimulation.

Uses- Norepinephrine may be given in the treatment of cardiogenic shock. Although the drug increases myocardial contractility, this effect is often offset by the systemic vasoconstrictor effects (afterload increase) that limit any rise in stroke volume. Increases in afterload may increase myocardial oxygen requirements, which may be a significant problem in ischemic heart disease."

I learned about this when I was studying for my anesthesia interview. The unit I currently work at doesn't use Levo often so I studied up on it for my interview in case they asked. Before then I had no clue that it had beta-1 effects. Its amazing what one can find in textbooks!

Artemis2 · May 5, 2006

Nursenary, you don't recognize me here but I taught you the same thing once upon a time and a few other tricks as well. I didn't realize that levo had any beta effects. I thought it was pure alpha. Even us old dogs can still learn a thing or two. It is no wonder that you found that info since I have never known anyone to carry as many textbooks as you in their backpack to work. I have never known someone who enjoyed studying critical care as much as you and as hungry for the nuances of the subject as you are. Did you get my email?

dfk, RN, CRNA · May 6, 2006

if i might add a sentence as well.. sometimes, when coming off pressors, especially levo, too 'quickly' can cause hypotension, but remember, they usually develop a rebound stabilization of pressure, as long as they are healthy, not on/off verge of sepsis, etc.. from what i have learned over the years, and by "quite quick to offer opinions" seasoned nurses, is to just give it a bit, and the pressure usually normalizes..

again, remember, this IS pt specific...

thanks for the sound off ! !

nursenary57 · May 7, 2006

Holy crap! I just figured out Artemis2 identity! I used to work with her! When I was waiting for shift change and I would see her walk through the door inside I would say "Thank God, someone who knows what they are doing and I can count on!" I learned a bunch from her and miss having her around. Thats why I tote around that bag full of books, because nursing school didn't teach me anything but Artemis2 did! Guys, you can ask her anything. I did get your email so check it when you get the chance. Great to hear from you!

dayplay · May 16, 2006

Titrating vasopressors require continuous and diligent monitoring of patient's response. Often times, it is titrated to effect. It's best to do a slow titration and then observe for any response. Sometimes, as patient condition's improve, you may continue titration within the ordered parameters. Goals with any vasopressors is to get them off these pressors if patient tolerates it.