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?

[applewhitern, BSN, RN]

Every job I have had as a nurse involved titrating drips! I have always worked ICU, but did a stint in our ICU step-down, and we certainly titrated drips there, too! This is the problem I have with nursing schools; they don't teach actual SKILLS anymore, and expect new nurses to learn on the job! When I started, we didn't have fancy IV pumps to figure drip rates for us, we had to do that ourselves.

[applewhitern, BSN, RN]

I just re-read your post. What do you mean, you hear lots of hospitals don't do it?? One cannot possibly call the MD every few minutes to get an order to titrate a drip! I guess I was lucky; my nursing school back in the 80's DID teach us these types of skills. When I worked with cardiac surgery patients, we would be titrating drips every few minutes! I don't mean to sound harsh; it just simply amazes me that we have so many nurses who say they never learned such-and-such in school. Right now we have a problem at my current hospital with nurses who are on orientation forever, simply because they didn't learn while in nursing school.

[Twinmom06, ASN, APN]

on our stepdown we will run dopamine but anything besides that will go to the unit as far as pressors go. We run heparin (titrate based on blood levels), cardizem (based on HR and BP) insulin (Q2 fingersticks) etc...

we are generally a 1:5 ratio

[dirtyhippiegirl, 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.

What do you titrate your pressors off of? Q15m cuff pressures? I can't imagine titrating TWO pressors that way although I realize nurses 30 years ago were hand titrating drips off q5min manual pressures or whatever.

[blondy2061h, MSN, RN]

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

Absolutely agree with that.

[blondy2061h, MSN, RN]

What do you titrate your pressors off of? Q15m cuff pressures? I can't imagine titrating TWO pressors that way although I realize nurses 30 years ago were hand titrating drips off q5min manual pressures or whatever.

Yep, though one of our step down units will do art lines also. Obviously not ideal. Like I said, by the time a second pressor is started they're likely in the process of being moved to the unit unless end of life discussions are pending. Part of the issue is our ICU truly has too few beds for the size of our facility. The unit I work on used to take all medical ICU patients, and we were a full fledged ICU in our own regard, but then for a variety of reasons that had everything to do with a changing patient population, that changed. So our ICU has always been more focused on surgical patients, and appeasing surgeons, and our medical patients are a second thought.

My hospital has many unique circumstances that I don't want to get into here, but the details of which would make this all a lot clearer.

[kerussll]

We do this in the NICU

[dirtyhippiegirl, BSN, RN]

Yep, though one of our step down units will do art lines also. Obviously not ideal. Like I said, by the time a second pressor is started they're likely in the process of being moved to the unit unless end of life discussions are pending. Part of the issue is our ICU truly has too few beds for the size of our facility. The unit I work on used to take all medical ICU patients, and we were a full fledged ICU in our own regard, but then for a variety of reasons that had everything to do with a changing patient population, that changed. So our ICU has always been more focused on surgical patients, and appeasing surgeons, and our medical patients are a second thought.

My hospital has many unique circumstances that I don't want to get into here, but the details of which would make this all a lot clearer.

Yeah. I'm not yelling at you for the way your hospital is run, obviously. It just makes me head hurt to think about doing that with two or three other patients to also take care of.

[blondy2061h, MSN, RN]

Yeah. I'm not yelling at you for the way your hospital is run, obviously. It just makes me head hurt to think about doing that with two or three other patients to also take care of.

Thankfully on my unit, it's doing that with one other patient to take care of. That would make my head hurt too.

[PMFB-RN, RN]

I can't imagine titrating TWO pressors that way although I realize nurses 30 years ago were hand titrating drips off q5min manual pressures or whatever.

We still do it that way occasionally on transport (ground and air ambulance / mobile critical care unit). Especially if we implement the drips ourselves. There have been times when I have even titrated drips like Levophed and dopamine without any BP monitoring, just basing rate changes on the appearance of the patient and feeling his pulse manually and looking for other signs of hypo or hypertension. It can be impossible to obtain a non invasive BP with the monitor, or hear a manual BP in the aircraft at times.

[VANurse2010]

Yep, though one of our step down units will do art lines also. Obviously not ideal. Like I said, by the time a second pressor is started they're likely in the process of being moved to the unit unless end of life discussions are pending. Part of the issue is our ICU truly has too few beds for the size of our facility. The unit I work on used to take all medical ICU patients, and we were a full fledged ICU in our own regard, but then for a variety of reasons that had everything to do with a changing patient population, that changed. So our ICU has always been more focused on surgical patients, and appeasing surgeons, and our medical patients are a second thought.

My hospital has many unique circumstances that I don't want to get into here, but the details of which would make this all a lot clearer.

A patient requiring more than extremely minimal pressors is an unstable patient that belongs in the ICU. The patient should be there long before they even get to the point of a second pressor being discussed (typically around 16-18 of Levo). Just because your hospital's staffing model dictates something, doesn't make it right.

[michlynn, BSN, RN]

I recently started traveling but at my home unit all of our patients were on tele so we basically did everything except for levo. Cardizem, nitro, amio, dopamine, dobutamine, insulin, lido. Our ratios are supposed to be 4-1 but were 5-1 most of the time. One day I was titrating 4 nitro gtts on chest pain patients plus dobutamine on another, it got so confusing. The ratios these days are definitely not appropriate.