Titrating multiple drips

[Good Morning, Gil]

So, I am a new nurse and new to the MICU. I love it so far and am starting my 4th week of orientation tomorrow. I have learned a lot so far and have had a good variety. However, I have had patients on 1 drip at a time, usually levophed for sepsis, but I have not had patients on 2 or more drips yet. (and have learned how to scribble things down on my little notepad b/c there's usually not time to chart right away lol). I read the icufaqs.org site on pressors and have a better understanding of ones that I have not encountered yet, but I think I really just need to study a good old fashioned drug guide, as well. My question is: how do you know how to properly titrate multiple drips? I'm so inexperienced at this point that I don't even know if this is a legitimate scenario or not, but say my pt is on levophed and neo at the same time? My understanding is that these have a very similar effect, so do you titrate the neo up first since it is less likely to cause tachycardia in your pt (more gentle than levo?). And if your pt becomes too tachy, titrate levo down, neo up? And, the docs would def. just try one drip first, right? If one drip doesn't work very well, why would adding one with a similar effect make any difference? I have only worked with 2 different drips so far. (levo and cardene). (I was surprised at how quickly cardene brings the pressure down, wow!).

In the MICU, how often will I have pts on multiple drips? Is this more of a CVICU thing? I will be asking my preceptor tomorrow, too. Is this just something that comes with experience, and I need I need to be patient? I just know I have a limited time on orientation, so I need to soak up as much as possible.

[Carrig RN]

I would titrate pressors and inotropes one at a time. Then if they don't tolerate it, it's easy to back track. You might wean Dobutamine to 3mcgs, then start on the Vasopressin or such. In the mean time you're adjusting the Insulin drip per the protocol. Of course, then you get the doc who throws you a curve ball and says; "Cut the Dobutamine in half, then in 30 minutes D/c it and pull the swan. I don't care about the index, or PA pressures. Then the pt can transfer this afternoon." To each, his own!

And when that happens, document, document, document. CYA as my preceptor always says :)

[Good Morning, Gil]

Thank you for all of the responses! I hadn't checked back here in a while, but it's interesting you mention the ischemic bowel. I took care of a patient with bowel issues that was on a a few pressors recently. Yes, don't want to make the bowel issues worse! I have learned a lot since then, my critical thinking has grown so much (still room to grow :)), and now I am off orientation (as of this week!). I always ask if I am ever unsure, but experience and reading has definitely helped!