Titrating and Bolusing

Specialties MICU

Published

So I am a new nurse about 2 1/2 months into an ICU internship program and while I've worked with some wonderful preceptors who are teaching me tons of great info, one area of ICU nursing that I'm still extremely uncomfortable with is managing drips. Just to preface, at my hospital ICU nurses have MD orders to titrate/bolus certain drips to desire effect (ICP, RAAS, MAP etc.) However, other than a card that has min and max rates (sometimes followed by "or higher") The amount a rate is changed or dose of a bolus is at the nurse's discretion. While I am starting to pick up some concepts, I am still miles away from being at the point where I'm not running to my preceptor every time so and so's VS are going beserk to find out which drips i need to bolus/decrease rate/increase rate and by how much??? When I ask them to explain I usually get the response that its something that comes with experience or it just depends on the patient. I am in NO WAY faulting them for not sharing the secrets of titration/bolusing as I realize that it is a complex issue that depends on a wide variety of factors that can't be explained properly during the occasional downtime we may have on this busy unit. So my question is does anyone have a reference/book they recommend for brand new nurses on this subject. The information I find in my nursing school books/the internet just doesn't cut it. I really want to become a competent nurse who practices safely and I am willing to do whatever it takes. I realize that this skill is truly built through experience, and I don't expect a book to make me an expert, I just need some basics to start with and build upon. Thanks all :-)

I would start by reading about the specific drugs you are titrating. Know how the drugs work is a key element in titration. You need to know onset, dosing, expected changes with titration, what the drugs do to the cardiac and vascular systems.....and most importantly you need to know which receptors which drugs interact with. A lot of it goes back to your sympathetic, parasympathetic system as well as receptors such as alpha and beta.

Start with the FAQ on Pressors on http://www.icufaqs.org

Specializes in Emergency Nursing.

(I work in the ED) When I was on orientation, I was thrust into critical care rooms. I had never managed multiple drips during my med-surg years. In my ED, we have a lot of autonomy in terms of gtt management. The one tip I'll give is what my preceptor told me: Be able to stand behind and back up any decision to bolus x drip or change a drip rate.

Meaning: Levophed titrated up (Document BP, pertinent assessment, or that you called pharmacy to make sure x dosing was correct)

This is just another tidbit: Always take a second look at lines, your patient, and your patient environment before deciding to titrate. Maybe your propofol isn't getting to the hub for whatever reason and that is why your patient isn't adequately sedated. BP is rising, cardene is not working...but you notice pt urinary output suddenly is 0.

I guess these things are all "duh." But for someone like me who was entirely new to managing multiple drips, this really helped!

I fully agree with the above poster about looking up your meds and doing some research. Also: Pharmacy is your friend!!!

Good Luck! I can tell you're on the road to being an excellent nurse just by being inquisitive :)

Specializes in NICU.

I work NICU, so the specifics are different. But I echo the idea of knowing how each drug specifically works. And then considering what you're treating. You're not just treating low BP. You're treating inappropriate vasodilation or poor CO or low intravascular volume, etc. So if you think you're patient is overly vasodilated, causing hypotension, for example, you may wean back you nipride. But this won't help so much if the problem is a really low CO due to poor systolic function of the heart. So it's slowly becoming an expert of assessment, physiology, and pharmacology that will really take time. But try to take the time regularly, especially if you're really uncomfortable in this area, to pick out one titration decision and review it later with your preceptor. Ask her to think out loud and list the factors that helped her know.

Definitely know your onset of action for every drip. Don't know them to the minute, but just know your Levo isn't going to work the millisecond you hit start. Also try and get a good grip on what the average patient requires for the drug. By now I can say most patients are good to go on 50 of Fentanyl and 5 of Versed for example. That doesn't mean 150 and 20 are unheard of, but if you have reached 150 and 20 and the patient is not responding you will then know it's probably time to look at other issues or consider another drug.

I'll second the "duh!" stuff too. I had a patient on about 30 of Levo one time and all of a sudden his BP tanked. Increased drip, nada. Went up to max rate and still had a MAP in the 40's. Figuring my Cordis would never go bad, it was the last thing I checked and sure enough the patient's leg was swollen like a fish. Quick switch to my triple lumen and he was fine and dandy on 30.

Specializes in MICU/SICU.

Second what everyone else said about knowing which gtts do what and how quickly. You could also try Kathy White's "Fast Fact for Critical Care Nursing". I'm pretty sure one of the med sections tells you what increments to go up in for each drug listed. Not every single gtt is listed but a lot of common ones are and it's a nice guideline. It's also a handy quick reference for those "duh" moments when you KNOW the drug's action but just can't pull it out of your brain at the moment :)

I really appreciate all of the feedback. I guess my main problem when they are on 3 pressors (levo/vaso/dopa) and 3 sedation drugs (fentanyl/propofol/versed), and deciding for example well x,y,z ALL cause this effect, but which one is most likely to be causing this and I should probably try decreasing first. Or the other day I had the doc say we need to start trying to get this pt. off of all of these pressors. The pt. was maxed out on his vaso and was on fairly high doses of dopamine and levo (from what my preceptor told me) and was sedated with fentanyl, propofol and versed. His MAP was not super stable (dropping below 65 and sometimes even below 60 throughout the night), his SBP was floating in the 90's, HR was usually between 85-100 and he was showing signs of poor perfusion in his ear and fingers. Since he was more than adequately sedated my thoughts were well lets ease up on the sedation and work on weaning one of the pressors. But thats as far as I can get. I know that all of the sedation drugs can cause hypotension, but I don't know which one is MOST likely to cause it. I also know that any pressor can cause poor perfusion to the extremities, but which one is MOST likely to be responsible for it? Again thanks for all the help, I really want to start getting the hang of this :-)

I forgot to add this as well to my thought process, and let me know if I'm going in the right direction or not: As far as sedation I should probably start with the propofol or versed and leave the fentanyl b/c the fentanyl will handle pain, propofol doesn't. Also I think I remember reading that longterm use of propofol isn't really desirable, and versed/propofol are more alike in terms of what you add them to achieve. (like most pt.'s i've encountered will start with fentanyl/versed or fentanyl/propofol, adding a 3rd when 2 isn't cutting it). As far as the pressors I was thinking maybe starting with the dopamine or vaso and leaving the levo alone. My reasoning behind this was i know dopamine can cause tachycardia (and the night before when I was with this pt. I had my first run in with SVT, but IDK if the dopamine had anything to do with this??) and also the vaso was maxed out so if something were to happen we couldn't increase it's rate to correct it. Then from there I think I narrowed it down to starting with vaso because the pt. had 0 urine output for about 2 days, and I thought I remembered that dopamine is good for renal problems b/c it vasodilates the renal artery (but then someone told me that they are currently questioning if dopamine is really THAT effective for renal problems) Also, in my experience so far levo seems to be the 1st pressor many docs will start (I think I remember hearing that its more specific for alpha receptors than the others so is less likely to cause undesirable effects on the heart through B-receptors), but other than that I don't really know why its the one they usually will start first. Another thought I was thinking when deciding to keep the levo around is because unlike the dopamine or vaso, there's not as defined max dose like the vaso and dopa so I can usually always go up on it if necessary (but I also was told that after going past certain dose that its not really effective anymore, but we were far from that on this pt.)

I think this pretty much sums up my thought process while I was staring at the pump at the bedside trying to make a decision. So critique away pleeeeassseeee :-) , especially if some of my thoughts were totally missing the mark. Better to be wrong now than later when these decisions are completely left up to me

You mention fairly high doses of dopamine and norepi....what were they? What is "maxed out on vaso" at your facility?

The max rate we can give vaso is 0.04 units/min and we his levo was on avg 0.5 mcg/kg/min and dopamine around 17 mcg/kg/min (max for this here is 20 mcg/kg/min)... I am still not really good at knowing whats high, low and avg doses, but when I asked my preceptor if this was alot she just said he was on fairly high doses.

Gotcha. We typically just turn the vasopressin on or off....we don't titrate it. We would have worked to get rid of that dopamine even if it meant having to increase our levo and titrate it down later.

I likely would have gently backed down from the propofol as well as down on the Dopamine. Did you have a CVP on the patient? Were they dry? Would some volume have helped? Were they on CRRT or HD? Mechanically ventilated? If so, how much PEEP?

As a new grad, you should check out http://www.icufaqs.org for some good basics of critical care.

Specializes in ER/ICU/Flight.

You mentioned that the levophed was at 0.5mcg/kg/m. I've never heard of weight-based dosing for norepinephrine. Our max is ~30mcg/m. We see levophed used as a 1st line pressor mostly in sepsis. You're right about the alpha effects, and it does have some beta-1 but not beta-2 properties (which makes it more desirable than epinephrine in some cases).

+ Add a Comment