How do you master inotrope titrations?

guest239592 · Dec 15, 2012

I am new to a trauma icu position and titrations seem second nature to the nurses in the unit I work with. My preceptor has been fantastic in making sure I have plenty of exposure to drips and titrations but I will admit I feel less than intuitive when titrating. I would love to hear others experiences and opinions.
Ah Drips, my favorite! :) Not a Trauma Nurse here, however I worked in a high-risk CVICU for 3 years (in anesthesia school now) so believe me we titrated every drip you can imagine (and had the luxury of PA catheters to help guide us!) Titrations are a tricky thing to learn when you're new to the ICU and honestly just takes time and experience until you will get a "feel for it". It really also requires a pretty in-depth knowledge of hemodynamics. With that said, here's some tips I can share until you get that experience eventually.
First thing always to ask yourself (with any medication) is why is the patient on it? For example, if a patient is on Dobutamine, is it more for inotropic support or vasopressor support (beyond 10mcg/kg/min)? Also look at parameters if your docs have given them to you (which they should) This should help guide your initial titration.
Keep in mind for most vasopressors and inotropes the effect is VERY fast, so if you're not seeing your effect within 10 minutes or less in titrating up (and 10 minutes is VERY long) you probably should continue to titrate. Also consider some of the basics such as the length of your IV tubing, the length of the central line (is it a long PICC or a shorter CVC) or PA catheter it's going into, the rate it's going at, and if it's infusing with anything else. For example, at our facility Vasopressin was mixed 1:1 100units/100mL. At a max dose at our facility of 0.1units/min the infusion rate came out to be 6cc/hr. Well if this is going let's say in it's own port with no other meds or IV fluids into a PICC line, it's going to take quite a while before the drug reaches the patient so you're not going to see the effect right away and you may need to infuse it with some main fluids initially to see effect. So consider things like that.
In initiating a drip, it's important to know what the max limits are. Check with your pharmacy at your institution as it can vary from institution to institution based on what they want their upper limits to be. Check your nursing policy and procedure manual in titrating invasive drips (there should be a policy on it) Also make sure to look at the order (for example some docs would say "titrate drug A up to Dose B to keep Cardiac Index greater than 2. If I reached the max limit they set even if it's not the facility max, I'd obviously be calling them directly for further orders).
Since the effects are so quick, a good general rule of thumb is "start low and go slow" For example if I started a norepinephrine drip on someone who's BPs were in the 70s, I'd probably start at 3-5mcg/min (even though you can go much higher believe me I've gotten there!) see how the patient responds, and continue to go up if I need to. Some pts I've put 5mcg/min on and they're in the 120s-130s right away, others are more sick and I need to keep going up. Individualize to your patient.
Know your drugs, how they work, and how they affect hemodynamics. For example, let's say I have a fresh postop heart who has a is hypertensive with BPs in the 160s (and pain has been treated) We commonly would use Nipride at my facility for it because it's potent, powerful and quick on/off. However let's also say this patient has a Hct of 37 and a CVP of 2. In this patient even though he is hypertensive, he is also hypovolemic and the second that nipride touches him and he dilates, he'll tank his pressures. So it would be prudent to give some fluids (of course per MD orders) along with Nipride (kinda sounds backwards I know). In this patient I would be VERY cautious as to how much Nipride I started them on, and start at a very low dose. As one of our CV-surgeons would say "Fill (with fluid) and Dill (dilate)"
In my opinion initiating a drip is much easier than weaning a drip. Weaning requires finesse and you really need to assess your patient's tolerance by looking at physical signs (first) vital signs and other clinical data that might be available to you (PA catheter, the new flowtrack catheters based off of arterial line, ScVO2 etc.) And please I know it's hard when your new to get caught up in only the monitor, but look at your patient. If I'm weaning a vasopressor and the pt is getting dizzy, diaphoretic, clammy etc. If their monitor is telling me their SBP is in the low 90s with a MAP right around 59-60, even though the numbers may not look terrible (like SBP 70s, MAP 50) their physical signs are telling me they are not tolerating the wean and either I'm going too fast or they're not ready yet. Either way I'm going to go back to the previous dose, give them a break and try again later (assuming nothing else is going with the patient). For this especially I like to start low and go slow. Depending on your docs, they may give you some weaning guidance, for example they may say something like "Wean this drip to off over the next 12 hours" In this case I would usually look at how much I was on and divide it out so every 1.5-2hrs I would go down little by little and see how a patient responds.
Once you start getting the hang of all that, then you'll start getting real sickies who are on CVVH or other machines and that adds another whole layer of complexity!
In summary, drips will become a daily part of your life as a staff nurse in the ICU. Never be afraid to ask others around you when you're off orientation for their advise. Make sure you know dosing ranges for your facility, and know your drugs inside and out. Get to know which drugs your Docs most frequently use. Once you get experience over time, titrating is something I really enjoyed doing because it gave me some level of decision-making and autonomy.
Best of luck in your new career!
Any further questions PM me :)

Sugarcoma, RN · Dec 16, 2012

Godfather, A very helpful, informative, and thorough post! Thank you!!!!

hodgieRN · Dec 16, 2012

You will use them often and after a while, you will know what to predict with each dosage change. You will learn which gtts are more potent. Some pts will drop their pressure by titrating Nipride only by 0.2. Others gtts are more "stable" with titration. The potency is important b/c you will know which of three vasopressors to concentrate more on. Other gtts are pretty much fixed. As time goes on, you will be able to titrate 3-8 gtts no problem.

sun78910 · Jan 3, 2013

Awesome post!!

Esme12, ASN, BSN, RN · Jan 4, 2013

Here is another discussion about this and a presser decision tree.

https://allnurses.com/micu-sicu-nursing/titrating-multiple-pressors-800346.html