Levophed concentration and hospital policy.

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  1. Levophed and PIVs?

    • 6
      We always run quad strength Levophed through peripherals.
    • 58
      Levophed through a peripheral?! Horrifying!!!
    • 30
      We run Levophed through peripherals, but only single concentration.
    • 4
      We almost never put art lines in patients on Levophed
    • 38
      We use art lines for our patients on pressors.

18 members have participated

Specializes in ICU.

Just curious about what your facilities say about the concentration of Levophed and what type of line you need to run it through. I work two ICU jobs right now - one full time, one PRN, and they both have very different ideas about how Levophed should be run.

My full time job says: You can only put single strength Levophed through a peripheral line, and they would prefer not to run it through a peripheral at all. Quad concentration has to be run through a PICC/central line. Quad strength Levophed is just too high risk to run through a peripheral.

My PRN job says: We always mix our Levophed quad strength and almost always run it through peripherals because almost none of our patients get PICC/central lines. Maybe Levophed is dangerous if it infiltrates, but patients needing Levophed are more likely to have some heart failure, and single strength Levophed is going to give them way too much fluid. Which do you prefer - the risk of a little bit of infiltration and damage, which should be low because you're going to be using a large vein for your Levophed anyway, or putting your patient on a vent because you overloaded them?

I am still firmly standing by my full time job's policy in that running quad strength Levophed through a peripheral scares the bejeezus out of me, but I can see my PRN job's point on the fluid overload standpoint. When you're running single strength Levophed at 30, and you're going through a 250ml bag in a couple of hours and some change, that's a lot of fluid if your patient is ARF or HF. Should we continue to run it single strength just because the patient only has a peripheral and there is no one available to drop a central line in that case?

What are your thoughts?

By the way, neither of my facilities typically place art lines when we have patients on pressors... but that is its own beast.

Specializes in ICU.

:nailbiting: My unit ONLY runs noradrenaline through a central line. If the pt is actively arresting, we might start an adrenaline infusion through a peripheral line until we get a central line. For other patients we will just use a metaraminol infusion until we get a central line. If your patient is so sick that they are on a normal strength noradrenaline infusion of 30 (!!!), they need central access ASAP.

Edited to add: all of our patients requiring inotropic support also get arterial lines.

Specializes in ER, Trauma ICU, CVICU.

I have run Levo through a peripheral before but it was only single strength and only for a short amount of time when I was trying to achieve better access. Patients on levo are sick enough to qualify for a central line. There is no reason to keep it infusing on a peripheral. I think that's asking for trouble!

We did not have a policy regarding the issue. But it was my personal policy to be a patient advocate and never infuse through a peripheral unless it was an emergency.

If my patient is sick enough for Levo, then they bought themselves a central line and an art line. I would never run Levo through a peripheral, but we only infuse quad strength. Our docs are great, so they get the line in so fast that usually by the time I get the gtt ready to go, they are done with the line. Plus we usually give some fluid and/or albumin before pressors anyways, so that buys me time. However, most of our patients are hypovolemic/bleeding/septic and not too many in HF so volume is usually not a concern.

Specializes in ICU.

I am jealous of where you all work. At both my jobs, only the ED physicians drop central lines on a regular basis - I saw a hospitalist try three times once, and butcher an IJ in the process. Surgeons will do it if they're around, which they usually aren't at night. Maybe some of the primary physicians can, but I almost never see any of them either. There are exactly two physicians in both of my hospitals at night - the ED physician and the hospitalist. It's pretty sad - one of these facilities is around 400 beds (48 ICU beds) and the other has 75 (5 ICU beds), and they have the same amount of doctors available. :no: If the ED physician is busy at either location, there's almost no chance of getting a line put in. It is very inconvenient. The physicians are much more likely to agree to getting PICC lines put in than proper central lines anyway, and PICCs are only dropped by IV therapy nurses, who are only in the hospital during the daytime... it really is pulling teeth getting anything done at night.

Specializes in ICU.
I am jealous of where you all work. At both my jobs, only the ED physicians drop central lines on a regular basis - I saw a hospitalist try three times once, and butcher an IJ in the process. Surgeons will do it if they're around, which they usually aren't at night. Maybe some of the primary physicians can, but I almost never see any of them either. There are exactly two physicians in both of my hospitals at night - the ED physician and the hospitalist. It's pretty sad - one of these facilities is around 400 beds (48 ICU beds) and the other has 75 (5 ICU beds), and they have the same amount of doctors available. :no: If the ED physician is busy at either location, there's almost no chance of getting a line put in. It is very inconvenient. The physicians are much more likely to agree to getting PICC lines put in than proper central lines anyway, and PICCs are only dropped by IV therapy nurses, who are only in the hospital during the daytime... it really is pulling teeth getting anything done at night.

:wideyed: I can't even... I know in the USA open ICUs are used but I didn't realise this meant that there are NO DOCTORS IN THE ICU. My unit is a closed unit with specialist Intensivists, and on a night shift we are staff by intensive care trainees. Where you work just sounds really dangerous.

Specializes in Critical Care.
I am jealous of where you all work. At both my jobs, only the ED physicians drop central lines on a regular basis - I saw a hospitalist try three times once, and butcher an IJ in the process. Surgeons will do it if they're around, which they usually aren't at night. Maybe some of the primary physicians can, but I almost never see any of them either. There are exactly two physicians in both of my hospitals at night - the ED physician and the hospitalist. It's pretty sad - one of these facilities is around 400 beds (48 ICU beds) and the other has 75 (5 ICU beds), and they have the same amount of doctors available. :no: If the ED physician is busy at either location, there's almost no chance of getting a line put in. It is very inconvenient. The physicians are much more likely to agree to getting PICC lines put in than proper central lines anyway, and PICCs are only dropped by IV therapy nurses, who are only in the hospital during the daytime... it really is pulling teeth getting anything done at night.

You have only 1 Physician on for a 400 bed hospital with 48 ICU beds? Even if this is (hopefully) only at night that doesn't sound like a hospital that should be taking patients.

Specializes in Critical Care & Ambulatory Primary Care.

I hate to say it, but this is more common than you think. I work in a small hospital with 12 ICU/CCU beds and we have to fight like crazy for a central line because again...only the ER docs drop lines (and the Pulmonologists who happen to be critical care specialists as well but are not "in house"). This means at night, there are no central lines dropped unless the patient comes from the ED with one, which also is rare. Therefore, we run levo in peripheral lines FAR more than I would want to admit. The risk is horrendous for the patients (not to mention the nurse's nerves). I fight for central lines on a daily basis for levo and other drips, not to mention simply obtaining a stable access for an unstable patient. It takes too long!

I hate the idea of the Open ICU. We have one hospitalist at night who covers the CCU as well as the whole house. During the day there are two hospitalists. I have not once seen the hospitalist place a central line, nor an arterial line. Most of the time, we have to consult the vascular surgeon to place a line which he does when he is out of surgery that day. Weekends involve contacting another hospital to call someone in to our hospital to do it (suffice it to say this RARELY happens as well). So scary, and so frustrating. I would love to have a closed ICU/CCU or to have a doctor that was fully capable of handling care of our patients.

Specializes in Family practice, emergency.

I work ED, but we are allowed to run levo through a peripheral until we get a central.

Specializes in ICU.
You have only 1 Physician on for a 400 bed hospital with 48 ICU beds? Even if this is (hopefully) only at night that doesn't sound like a hospital that should be taking patients.
Oh yes, there are physicians coming out of our ears on day shift, but there are only two in the hospital at night - hospitalist and ER. The hospitalist service is not always consulted on every patient (what is the point of that? why even have hospitalists if we can't always use them?) so occasionally I will call other physicians, which means waking up someone sleeping in his bed at home. Very rarely, one of these physicians will show up at the hospital if something goes down. I have seen physicians show up in what clearly look like pajamas before, though it has been a long time since I've seen a physician actually come in on the fly for any reason. Surgeons are most likely to actually wake up and drive to the hospital if there's a real problem, if I can keep them on the phone long enough to convince them not to cuss me out and hang up on me for bothering them about something "trivial" like an abdominal surgery patient who completely stops producing urine, or someone whose hemoglobin is still "high" around 10 but has experienced a four-point drop in the past few hours since surgery...

Hopeinchrist03 - I am right there with you. Many of the hospitalists are all but useless anyway when it comes to critically ill patients. I have had hospitalists try very hard to kill my patients before under the guise of ordering "helpful" things... sometimes we can redirect them and sometimes they are absolutely sure their orders are right. I am really shocked at some of the patients I've had who have lived despite the hospitalists not wanting to order more aggressive treatment. I guess patients are harder to kill than we think they are.

Specializes in MICU, SICU, CICU.

I once worked in similar hospitals with doctors who were unable or unwilling to come in and place a central line for administration of pressors. At that point I would ask for a Surgeon to place the line and usually they would come in at night and do it. Do not accept an ER pt on pressors if you doctors cant or wont place a line.

I would give standard concentration norepi 8mg/500 only to a good antecubital vein until central access is available. Quad strength never. No way.

Working under these conditions it is good to know how to give regitine. Mix it in ten cc of nss. Dont pull or flush tne iv Using a small subq needle give small amts in a circle around the infiltrated iv site. Give the other 5 cc through the iv so that it reaches the extravasated norepi and neutralizes it. then pull the iv.

Specializes in MICU, SICU, CICU.

In general, do they cautiously fluid resuscitate the CHF pt before starting pressors? If renal perfusion is restored, and the uo is adequate, I dont see why standard concentration levophed would pose a danger. Less dangerous than quadruple strength levophed given peripherally imho.

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