Do you titrate drips?

[LittleRedOwl]

Ive started to wonder out of curiosity (because I've only worked in one hospital system)... how many hospitals have nurses titrate cardiac drips? It wasn't anything I was taught in school and even at my job I hear rumors that lots of hospitals don't do it.

Basically on my floor (stepdown) it's very typical to have a patient on a cardiac drip like dopamine, levophed, cardizem, lidocaine etc... and we'll be given parameters to maintain such and such map or sbp. Meaning I adjust dosing based on my judgement.

So my question is, do you do this where you work as an rn?

[Swellz]

I work on a tele/oncology floor, and we do diltiazem and amiodarone drips. They aren't that common for us though. Our ratios vary, but in general 3-4 days and 4-5 nights.

[nurseprnRN, BSN, RN]

You know, it's not much different at all from sliding-scale insulin. You have parameters for dosing, and you monitor them and adjust the dose. No biggie. Just be sure you know what the drug does.

I cringe to remember when, as a first year new grad in critical care, asking in a smartmouth fashion why we gave dopamine to increase blood pressure and nitroprusside to decrease it at the same time, and how was I to know which one to screw with at any given time? Fortunately, somebody took pity on my ignorance (and prevented me from looking like a jerk in the future, at least over this issue) and explained it to me.

[ixchel]

My stepdown does titrate drips. I haven't seen levophed on my unit, but I think it can be done. I think if he patient isn't going to be an ICU transfer, we'll do dopamine before anything else, provided boluses didn't work.

[littlepeopleRNICU]

I work NICU, but yes, we titrate drips.

[LittleRedOwl, ADN, ASN, BSN, RN]

I agree, it's not very hard titrating the doses once you get a feel for it. The ramifications are just much bigger than a typical sliding scale if you ask me -and can require a lot of babysitting and judgement. Giving someone a few units of insulin and checking their sugar at their next meal hours later requires much less attention than monitoring blood pressures every 15, 30 or 60 minutes when a couple mcg's might make the difference between a systolic in the 100's vs in the 70's. I can only imagine the liability if a patient were to have a bad outcome from poor monitoring on a nurses part. It just got me wondering how different hospitals treated such patients. For instance, I work with a nurse who recently traveled and worked in a different state's stepdown unit for a year and returned to us, and she said they were all shocked there to hear about our hospitals scope of a stepdown nurse working with drips. Just comparing experiences

[amzyRN]

I worked in a cardiac stepdown in the midwest and we titrated nitro and cardizem but that's it for the vasoactives. We also had insulin drips that we titrated. The insulin drips would be a 4 to 1 ratio, but with cardiac drips the ratio was as high as 5 to 1.

[VANurse2010]

Most of our patients have some sort of central access regardless. We have a 24/7 infensivist who can place CVL's whenever needed. Any nurse can assist with that, as it's just a matter of gathering supplies. We have a dedicated line placement cart that we can grab that has everything on it. Then, after the patient is stable, we can worry about restocking it.

No dose limit on the Levophed. Max of two pressors outside of ICU. ICU is notified when a second pressor is started so they can prepare for a transfer if needed. There is always an open rapid/code bed in ICU if we need to move the patient energently.

Sounds overly invasive for a non-ICU. I wouldn't allow my family to be under that regime.

[Dranger]

Step down- dopa, dobu, cardizem, nitro etc etc

ICU- everything

[PMFB-RN, RN]

Yep, totally standard nursing stuff.

[blondy2061h, MSN, RN]

Sounds overly invasive for a non-ICU. I wouldn't allow my family to be under that regime.

But what makes an ICU an ICU? We have 1:2 ratios when doing cardiac drips with active titrating, we attend the same cardiac classes the ICU nurses attend, and we have most of the same cardiac monitoring equipment ICU does. In all honesty, if they need a second drip we're usually working on transferring them to ICU.

[Here.I.Stand, BSN, RN]

But what makes an ICU an ICU? We have 1:2 ratios when doing cardiac drips with active titrating, we attend the same cardiac classes the ICU nurses attend, and we have most of the same cardiac monitoring equipment ICU does. In all honesty, if they need a second drip we're usually working on transferring them to ICU.

It's not that stepdown or floor nurses can't learn to manage drips. It's that some of the ratios I see in this thread make it very difficult to watch the pt as closely as they need to be. Three and four pts when one is on Levo does not seem safe...and then when one goes on break and the other nurses have to monitor her pts and theirs? It just seems like a really bad idea to me.

Just my $0.02

[emtb2rn, BSN, RN, EMT-B]

Yep, all the time in the ed. One of our docs gives verbal parameters of "titrate to life" for pressors. She then puts in cpoe with actual parameters. One of my favorite docs.