Vasopressin- Usage and dosing

  1. At the hospital I now work at we have just started using vasopressin on hypotensive pt's from sepsis, the dose the doc wrote was o.o4U per min and not to be titrated. I also work at a large Level 1 trauma center and we use it with range of 0.01-0.04 units per minute and titrate to blood pressure. I had a big discussion about vassopressin after I wrote up a nurse from titrating the drug beyond the limits for a septic patient and she could have caused harm to the patient by making her organs ischemic. The drug was running at .2u per min. which is to high for the septic patient. Whats your opinion?
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  2. 8 Comments

  3. by   Janet Barclay
    Quote from trvlnurs
    At the hospital I now work at we have just started using vasopressin on hypotensive pt's from sepsis, the dose the doc wrote was o.o4U per min and not to be titrated. I also work at a large Level 1 trauma center and we use it with range of 0.01-0.04 units per minute and titrate to blood pressure. I had a big discussion about vassopressin after I wrote up a nurse from titrating the drug beyond the limits for a septic patient and she could have caused harm to the patient by making her organs ischemic. The drug was running at .2u per min. which is to high for the septic patient. Whats your opinion?
    Hi, I have seen doses beyond the usual .01-.04 u/min, but only for severe GI bleeding (because I'm old ). It does cause serious ischemia including the myocardium, but it is coming back in vogue for sepsis. Janet
  4. by   godfatherRN
    I work in a Cardiovascular Intensive Care Unit. We use vasopressin ALL THE TIME. Our surgeons hate levo and phenylephrine (and there's research that suggests pt's having low endogenous vasopressin levels after bypass)

    Our max dose range is 0.1 units/min. However I've seen the docs write orders to titrate up to 0.2units/min, and just yesterday had a pt where we could go up to 0.3units/min (we ended up doing that AND had to add levo, she was on CVVH I might add at zero net loss of course!)

    A few months ago our pharmacists told us they are working to put a hard stop in our smart pumps to not allow us to go up to this range because there's evidence that beyond 0.1units/min there's the effectiveness of the drug drops way off, and the risks outweigh the benefits.

    Obviously, treating a septic pt vs. a CV pt is like comparing apples to oranges, just thought I'd throw my 2 cents in as to what I've seen in my practice.

    Oh and btw, as far as your co-worker I would have done the same thing and written an incident report. Wether the doc wants to go beyond the recommended range is up to them, but you can't just do "maverick" nursing like that, it's dangerous and illegal if you don't have prescriptive authority. I think you did the right thing (plus if you weren't meeting BP goals at 0.04 and needed to go up to 0.2, I would think you would probably want to LET THE DOC KNOW!!!!)
    Last edit by godfatherRN on Dec 22, '10 : Reason: Added more writing
  5. by   TylerDurdenRN
    "Maverick" nursing made me laugh out loud. Awesome.

    And I agree, if parameters are not written, and the order says a generic start at X and titrate to maintain MAP > X nursing judgment has to come into play when titrating such drugs. If i saw an order that seemed out of range, especially with a drug like vasopresson, I would not only of course assess the patient for why such an order was written, I would check the MD's notes, call up the pharmacy and ask about dosing and possible adverse effects(we have amazing pharmacists who go out of their way to find everything possible out for us), look in a drug book, and call the MD to ask their opinion. I have no pride about these things, calling the MD's and saying "I don't completely understand this order, please explain it for me" not only educates you, but its just safe for the patient.

    But seriously, the nurse that went up that high without calling an MD or at least doing some research and talking to other employees, needs to seriously be called into question.
  6. by   litepath2
    Quote from trvlnurs
    At the hospital I now work at we have just started using vasopressin on hypotensive pt's from sepsis, the dose the doc wrote was o.o4U per min and not to be titrated. I also work at a large Level 1 trauma center and we use it with range of 0.01-0.04 units per minute and titrate to blood pressure. I had a big discussion about vassopressin after I wrote up a nurse from titrating the drug beyond the limits for a septic patient and she could have caused harm to the patient by making her organs ischemic. The drug was running at .2u per min. which is to high for the septic patient. Whats your opinion?

    My opinion is whatever your protocol says, IS the Way it Shall be! Yeah, I might write an incident report, but you asked what we think, Protocols (and following them) whether we agree or not are the only thing that actually saves us when a case goes bad. Of course documentation runs a close second!

    Other than that, I like Vassopressin! It may cause ischemia, but so will lots of other things mechanical and chemical. I like to go with the pt. assesmsment and allow that to guide me: protocols not withstanding!

    As to the Mav-Nursing! Seen it...not pretty! Maverick, John-Wayne...great actors! Not Nurses though!
  7. by   ShaunES
    Our septic patients start on noradrenaline (nor-epi/levophed), once they hit about 30-40mcg/min, we start vasopressin at 0.04units/min, and from there we can wean the noradrenaline down, but keep the vasopressin going.

    This way we use the optimal pressor (norad), until we get to doses that are getting to the point where we need to add more in (usually we cap at 40-50mcg/min), and from there add in vasopressin.
  8. by   Da_Milk_of_Amnesia
    Quote from ShaunES
    Our septic patients start on noradrenaline (nor-epi/levophed), once they hit about 30-40mcg/min, we start vasopressin at 0.04units/min, and from there we can wean the noradrenaline down, but keep the vasopressin going.

    This way we use the optimal pressor (norad), until we get to doses that are getting to the point where we need to add more in (usually we cap at 40-50mcg/min), and from there add in vasopressin.
    30-40 mcg/min ?? Uhh where you work? You know you start clamp down on the bowel circulation enough to cause a necrotic bowel at with levo @ >20mcg/min? Not smart in my opinion. Vaso is usually our last line pressor. We usually will go to Neo if levo doesn't work. If levo and neo dont work then we add vaso and start it wat .04units/min,
  9. by   ShaunES
    http://www.srlf.org/data/Upload/Consensus/pdf/50.pdf


    This study has the patients in severe sepsis on an average of 0.45mcg/kg/min of noradrenaline, with a maximum of 1.06mcg/kg/min.

    While there is still a lot of mystery in when you should add more vasopressors, a limit of 20mcg/min seems to be less than evidence based.

    Showing good outcomes on 1mcg/kg/min is surprising, that's a lot of noradrenaline isn't it, like I said we like to add in vasopressin/adrenaline at 30-40.
  10. by   MomRN0913
    We do not have clear guidelines in our hospital on Levo. It is "said" 30mcgs is max. We have a hospitalist who says there technically is no max. I read it can go up as high as 68mcgs.

    Vasopressin in my hospital does not go above 0.04units/min. for septic shock and I have never seen it ever go above that in my institution, we add another pressor.

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