dobutamine

I am a student nurse and I have a question about dobutamine. I had a patient today who was on dobutamine 10mcg/kg/min. Now the MAR said "titrate". I didn't really think about it until I got home. I know what dobutamine is for. inotrope, increases conduction in Av node, increases contractility, stroke volume..... anyways, this patient was only on a cardiac MONITOR, he had a picc line, but it was not hooked up to a transducer to get CVP readings.

So, my question is.....how are you supposed to titrate dobutamine in this situation? I mean, w/ a pt only on a heart monitor. Other than maybe assessing rhythm, HR, BP, Urine output??? Cause the action is an inotropic affect that increases stroke volume (from what I understand) and if you don't have a way to measure that (like CVP's), how can it be titrated?

That would be about it. I've worked in and around critical care for about 10 years and have not used dobutamine all that much, but have used it on a cardiac tele floor, and those assessments (rhythm, HR, B/P, UOP) are what we used. CVPs/Swans are not used as much as they used to be, even in ICU.

Hope that helps,

Jilly

I am a student nurse and I have a question about dobutamine. I had a patient today who was on dobutamine 10mcg/kg/min. Now the MAR said "titrate". I didn't really think about it until I got home. I know what dobutamine is for. inotrope, increases conduction in Av node, increases contractility, stroke volume..... anyways, this patient was only on a cardiac MONITOR, he had a picc line, but it was not hooked up to a transducer to get CVP readings.

So, my question is.....how are you supposed to titrate dobutamine in this situation? I mean, w/ a pt only on a heart monitor. Other than maybe assessing rhythm, HR, BP, Urine output??? Cause the action is an inotropic affect that increases stroke volume (from what I understand) and if you don't have a way to measure that (like CVP's), how can it be titrated?

YOu're right for being confused about this, as it is an odd order. If you're sure the drug was dobutamine...and you're sure the order was an open-ended 'titrate'... The order was mis-read, mis-written, or just bad. Tele, step-downs, IMCU's routinely get these types of patients and CVP's arent really necessary (though always nice).

My best guess is that the order was a 'target' dose of 10mcg/kg/min and the nurse was to start low and titrate up to target. THe reason you would titrate this is because sometimes patient's have trouble tolerating it (hyper or hpo tension, arrhythmias (esp. pvc's!)...so you dont want to bomb them with 10mics all at once. STart at like 2mcg's or so and go up slowly until you reach target...keeping an eye on their hemodynamics(meaning: bp, hr, rhythm).

Dont worry about the MAR. Go look the order up and you'll have a better idea of what the doc wanted...it'll clear this up for you i think.

I am just a new grad in ICU and I don't find this order very odd at all. Am I missing something here? If so, can someone clarify...

My understanding is that dobutamine is an inotrope which is used to increase cardiac contractility. It makes the heart pump more efficiently. This would help decrease preload (CVP) and afterload, and increase SV.

Usually when we have dobutamine ordered, we may or may not have the means to measure CVP. For the most part, we would monitor BP and UOP to determine effectiveness. It seems that measuring CVP would be helpful, but not required to titrate.

When titration orders are written, they will usually say Dobutamine gtt titrate to ....whatever "MAP > 60, BP in a certain range;etc. So to write a order that says Dobutamine 10mcg/kg/min titrate is an odd order that needs clarification. Is that the goal or max that the doc wants or is that where he wants to begin??? So a clarification order is in need for this patient. I agree with CVryder, while cvps and swans are more accurate they're not used as often. In our ICU we closely monitor the hr, and frequent bp's..along with everything else, like urine output and overall pt assessment. Our patients that have swan's usually have severe heart issues that a regular BP cuff can't accurately gauge. Hope this helps.

alex1

CI would be ideal for titration of dobutrex. in the absence of a swan sbp, uop, and cvp would be next best.

The OP said pt was on 10 mcgs and the mar simply said titrate. Typically you have parameters both for dosing and hemodynamics. I typically wean as tolerated as long as my hemodynamics are acceptable. I'm in CVI so things are a little different, we have a ton of autonomy in our unit. Always wean dobutrex slowly especially in people with poor EFs.

I am a student nurse and I have a question about dobutamine. I had a patient today who was on dobutamine 10mcg/kg/min. Now the MAR said "titrate". I didn't really think about it until I got home. I know what dobutamine is for. inotrope, increases conduction in Av node, increases contractility, stroke volume..... anyways, this patient was only on a cardiac MONITOR, he had a picc line, but it was not hooked up to a transducer to get CVP readings.

So, my question is.....how are you supposed to titrate dobutamine in this situation? I mean, w/ a pt only on a heart monitor. Other than maybe assessing rhythm, HR, BP, Urine output??? Cause the action is an inotropic affect that increases stroke volume (from what I understand) and if you don't have a way to measure that (like CVP's), how can it be titrated?

I am a CCU nurse and CVP is not an indicator of cardiac output. Many patients with heart failure have elevated cvp's , which is normal for them. The have large hearts. Heart rate, bp, urine output are essential. If titrating for cardiac output a PA catheter may be inplace for cardiac outputs and indexes.

I am just a new grad in ICU and I don't find this order very odd at all. Am I missing something here? If so, can someone clarify....

The 'odd' part of this order is that according to the OP, the MD left an open-ended 'titrate'. Which, as you know, is not done if you're at the ordered dose. (yes you many times titrate up, but once there the 'titrate' aspect of the order is moot).

Or, the order WAS written to titrate to target, but the OP just didnt realize it...Or,the OP wasnt sure how to titrate up (or what to watch)...Or...i misunderstood the OP?

*And usually when 'titrating' dobutamine, it's not typically done by watching its 'effectiveness'(meaning, is the UO better?, CVP better?, PAP, etc...) but rather it's 'titrated up' because it's many times not tolerated by certain patients and/or at higher doses. This becomes more obvious when you consider the volume of dobutamine drips started on tele floors without the capacity to monitor CVP's/PAP's, etc.)*

Sure, if the MD thinks a higher dose would make a difference he'd then (the next day?) order a higher dose...(and probably a 'titrate' to target type as well)

I am also a CCU nurse (albeit a new one) and am not sure why there are all these mentions to CVP. Our orders are written to parameters - typically to MAP >60 using an art line. We have a lot of autonomy as well. UO may or may not be an effect you see, but that would not be as immediate as BP.

Stephanie

i am also a ccu nurse (albeit a new one) and am not sure why there are all these mentions to cvp. our orders are written to parameters - typically to map >60 using an art line. we have a lot of autonomy as well. uo may or may not be an effect you see, but that would not be as immediate as bp.

stephanie

but dobutamine doesn't always have an effect on blood pressure. and when it does, it may make it go up or down.

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[color=#483d8b]i've never truly titrated dobutamine without a pa catheter in place, and then it was always to the ci. sometime we would have to add a dopamine drip to counteract the blood pressure lowering effects in certain patients.

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Next time call the doctor and say 'titrate for WHAT??'

This was really unclear and not fair to you. Dobut is great to get people out of heart failure but 10 mcg is a hefty dose. I'd want to know just what that MD was thinkin.

i always get those kinds of orders with dobutamine as well as dopamina.. titrate only means that u increase the drop factor every 5 mins (maximum of 50 gtt) till you reach the desired BP.. thats what we always do

This is interesting to me.

In CVICU, I usually titrate dobutamine to CO/CI with the occasional order of MAP >/= 60 and it was with an A-line and SVO2 or manual CO setup in place. To me it seems the most logical given the effect. For BP, we usually go from Levo to Vasopressin. We may or may not see a UOP improvement with dobutamine. Usually, if we do, it is the patient who starts out with the post-op EF of 20-30% (or those lovely 15%ers) who are the most notable. For them, ANY pumping help has a good potential to increase UOP.

In our facility, this gtt is not administered on the floors. However, I do agree, this is an unfortunate order for any nurse to come across and certainly needs a follow-up for clarification. 10mcgs.. BAM! wow. Not so sure about that. Dobutamine...start low, go slow.

I would like to know the usual parameters used if CVP is monitored for this. This is just for my learning purposes as I have never done that before in the years I've been working with it.