Do you titrate drips?

flipflopsNsweetTea · May 20, 2015

We don't titrate on our stepdown unit. We do cardizem, dopamine, dobutamine, heparin, amnioderone, nitro, insulin...those I can think of off the top of my head. The cardiac gtts run at a rate ordered by the MD and when the pts meet certain parameters, the MD will give orders to change the rate or d/c..or Tx to the ICU for more close monitoring or a different gtt. With cardiac gtts, we have a 5:1 ratio, with insulin it's 4:1 (most days). With insulin, we have a nomogram that we follow based on previous and current blood glucose.

Here.I.Stand, BSN, RN · May 20, 2015

My head is still reeling at the notion that 4:1 and 5:1 are considered appropriate stepdown ratios by some management. Those are floor ratios. :banghead:

Sugarcoma, RN · May 20, 2015

I work in a combined ICU/SD unit. We take insulin,cardizem, nitro, cardene, and amio as stepdowns. Levophed buys you ICU status. Occasionally we will have that odd patient we just can't wean off levo who is on 2-4mcg as a stepdown. We do not use dopamine often at all but occasionally we will have a low dose dopa patient on stepdown as well.

Cardizem has a limited range and is usually not titrated aggressively. I have only used it a couple of times for resolution of A-fib. I think a cardizem patient with a stable bp would be appropriate for SD. Same with Cardene as long as BP is not rising. Dopamine only depending on why. I have mostly seen dopa used for symptomatic bradycardia. As long as the range is small say 5-15 mcg and the HR and BP are remaining stable I would be ok with this as a SD patient.

Levophed is an entirely different animal in my opinion. I really do not think levophed is appropriate for SD. We use levo for septic patients. As another poster pointed out a septic patient requiring levo for support can turn into a hot mess in no time flat. Do you have a central line and an art line? What is the range you can titrate to and what are the parameters? At what point does your SD on levo become an ICU? 10mcgs? 20? How do you do vitals in your unit? Do you have monitors that pull your data in or do you need to do manual vitals? Do you have docs readily available to you?

I would encourage you to do two things. First, pull up your facilities policy and procedures related to levophed (and the rest of the drugs you mentioned). My hospitals policy requires anyone on levophed to have a central line once you go past 5mcg. Vitals are required Q 15 minutes and they require an art line and a foley catheter for critical I's and O's. The policy also states we can titrate Q5 minutes. In my opinion anyone requiring Q5 minute assessments belongs in the unit.

The second thing I would do is find your hospitals unit admission guides. This should give you a rough idea of what is considered ICU versus Step-down. I would want to double check for myself that hospital policy states someone on levophed is appropriate for step down and see exactly what it says about at which point that patient should go to ICU.

VANurse2010 · May 20, 2015

My head is still reeling at the notion that 4:1 and 5:1 are considered appropriate stepdown ratios by some management. Those are floor ratios.

I worked on a "PCU" where the max. was 6. That didn't happen everyday, but it wasn't rare, either. We didn't take insulin or titrate, but you could easily have people on Lasix, dobutamine, amiodarone, cardizem etc. and a fresh stroke admit.

ixchel · May 22, 2015

My head is still reeling at the notion that 4:1 and 5:1 are considered appropriate stepdown ratios by some management. Those are floor ratios.

This is our current matrix and it sucks. I can't tell you how much I absolutely ADORE my unit, the MDs and fellow nursing staff. If it weren't for them, I'd be looking at employment listings. I've been so exhausted, so run down, and so burned out by 5 patient ratios on a floor that I was promised would never be more than 4. I get told I should feel fortunate because it used to be 5 was expected every shift. THAT'S NOT OKAY!