Cardiac Gtt Titration

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Does anyone have policy, procedures or guidelines with titrating off cardiac gtts - cardizem, dopamine, nitro., ect - hospital has no policy or guidlines. Thanks Ottoma

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Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.

Uhhh...:uhoh21: Not touching this one with a 10 foot pole. I would assume that your medical team would want some kind of protocol, so they don't have to give an order each time the med has to be titrated up or down.

Are you on ICU or stepdown?

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Uhhh...:uhoh21: Not touching this one with a 10 foot pole. I would assume that your medical team would want some kind of protocol, so they don't have to give an order each time the med has to be titrated up or down.

Are you on ICU or stepdown?

I am on a regular telemetry unit. MD orders are usually titrate to specific SBP or HR, starting dosage and maximum dosage, but no parimeters how to get to maximum dosage or how to titrate off. Hospital has no procedures or protocols and the RNs questioned on how they "do it" are different. Even the clinical was upset with me when I questioned dosage and timeframe to wean dopamine off pt. Also had to start a cardizem gtt on same pt. MD order was to give 5mg bolus and start at 5mg upto 20mg (max is 15mg on unit) and no other info. No intervals for VS, increase of med, or timeframe. Very uncomfortable with this so called policy. No protection for RN or pts in this facility.

If you have any guidelines, would appreciate.

Thanks,

Ottoma

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Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.

http://www.icufaqs.org/

Here is a great reference site. Click on the Pressors & Vasoactives link. Once you get that page up, scroll down to Dopamine, etc. (#21, I think).

I feel for you. What is the nurse-to-patient ratio on your floor?

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http://www.icufaqs.org/

Here is a great reference site. Click on the Pressors & Vasoactives link. Once you get that page up, scroll down to Dopamine, etc. (#21, I think).

I feel for you. What is the nurse-to-patient ratio on your floor?

Thanks for the link. I guess I should not complain, because I have read where the ratio for some RN's on telemetry is 9:1, but we are 4/5:1 usually, usually without an aid. We do have fresh cath pt. where we pull sheaths, titrate gtts, and have some vent pt. Administration is trying to make us a stepdown unit - but we do not have the training or the personnel.

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Specializes in Utilization Management.

Our policy is that we do not titrate on Tele. Only Critical Care units can titrate, and they have standing orders to do so for each med.

The rationale is that if a patient needs to be titrated, they require closer monitoring than we on a Tele unit can provide.

So we tell the doc ordering titration that they need to send the patient out of our unit. Very often the doc will elect a non-titratable drip and see how the patient does.

We usually have parameters for any drip orders, and if I have a patient who's on a drip and they don't have parameters for some reason, I'll call and get parameters before the med needs to be titrated or taken off.

So sometimes we'll see an order that has parameters resembling titration, e.g.:

Cardizem 5 mg/hr if HR sustains at 60-120, increase without bolus to 10 mg/hr if HR sustains >125 x 5 minutes with SBP >90. DC if HR

Orders like that are pretty rare, however, and usually the doc will only do it if he's got a patient who's a DNR and who wouldn't normally be sent to ICU.

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I WORK ON IMCU WE TITRATE I DONT LIKE TO GIVE A BOLUS AS LONG AS TH BP IS 90 SYSTOLIC BUT THE MOST WE CAN GO IS 20 MG PER HOUR I TRY TO KEEP A CLOSE EYE ON TELE CAUSE THEY CAN CONVERT AND HAVE A RASTE OF 50:uhoh3:

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Specializes in Cardiothoracic Transplant Telemetry.

On our floor we can have stable gtts, but are only supposed to titrate Nitro to bp and chest pain. We also titrate Cardizem sometimes with very specific parameters. Several months ago I had a patient on Dopamine at a low level, and the doc ordered that the gtt be weaned to off overnight. I argued that "weaning" is just another word for "titrate", but lost the argument. Sure enough, the patient dumped his pressure in the middle of the night and we had to call the doc for orders to turn the gtt back up again. So I had a patient that was essentially on q 5-15 minute bp's all night. Frankly I thought it was stupid to "wean" a pressor in the middle of the night when the patient was asleep and would have lowered blood pressures anyway. They were able to wean the gtt down during the day, and the patient was fine. To me anytime we are changing the rate, it should qualify as titration, and we should either do it or not do it.

This order was also written by one of our favorite docs, the one that I go to personally, and I think that we let him get away with murder sometimes and stretch the rules because he manages his patients so well. The problem is that situations like this set a precident, and then we have to deal with the docs that you have to beat over the head to get decent orders from. "Well, you did it for doctor so and so....." argh

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That ratio is too high if you do not have CNAs and are taking care of vents and pulling your own sheaths in addition to titrating gtts. Tele floor should not be titrating nitro - if pt is on nitro gtt then he is too unstable and should be in ICU. You should have protocols for monitoring vs with each particular med. Usual is like Q15x4/till stable after start or change, then q30x4, then q1hr, stable pts can be q2h if no changes or problems. Pt's could be going bad while you are pulling sheaths and holding pressure. Please tell me that they have trained the staff how to pull sheaths. Your floor sounds scarey and if I were you I would be looking for a new job. Sounds like they have cut staffing to the less than the bare minimum for such high acuity patients. Too dangerous for my blood.

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Specializes in Travel Nursing, ICU, tele, etc.

Pheww......you are in a dangerous situation, my dear. You should not be titrating drips outside the ICU, there are just too many factors involved and you have too many patients to watch. I would high-tail it out of there... Perhaps working in an ICU is what you want to do but you and your coworkers don't have the training or the support from your leadership where you are now. A lot of what you are describing is ICU level nursing. You should not have to go to the web to find out how to deal with Dopamine or Cardizem drips, that is totally unacceptable and absurd. I would get out and then report that facility. They are on their way to killing a patient or two and the untrained nurse who tried to take care of those patients may never get over it.

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Specializes in Emergency.

As a tele nurse with >1 year experience I agree that you should not be titrating those meds on a unit outside of ICU or PCU. We do use weight based parameters (xmg/kg/min), but those are easy to calculate, and we use pumps that will figure it out for you based on current weight. We have the policy that if a pt needs titration they are sent to a critical care unit where the nurses are trained to do it.

If your hospital/unit has no policy on this I would be very leery of continuing to work there...Remember the patient has the right to safe care, and if you are not an ICU/CCU nurse trained specifically to do this they could die. It also your license on the line because no matter what the MD wants, you will be held responsible for any mistakes. I don't want to scare you, but I would not want to be in your shoes if something happens to one of your pts.

If you want to work in cardiac, find a hospital with good policies and practice guidelines.

Amy

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