Dobutamine without a Swan and use of Dopamine

[maloneys]

I'm a little confused about the practice at my current work place. I see Dobu Rx'd for patients without a Swan. I feel strange administering without understanding how we can titrate without a Swan? Do others see this?

Also, in said workplace, docs Rx Dopamine before Levo on a regular basis. It's often infused peripherally as many pts don't have central access. I often feel like I'm the only one complaining about this. RNs there don't form a united front against this: "life or limb", they say. Anyway, just wondering what people think about this, and also if they are also seeing Dopa use as a first generation pressor. Thank you!

[NeoPediRN]

At my hospital dopa is usually first line for persistent hypotension/bradycardia and it is given through a #20 or larger IV. It depends on the patient's underlying condition what kind of pressor they get though.

[umcRN, BSN, RN]

At my hospital dopa is usually first line for persistent hypotension/bradycardia and it is given through a #20 or larger IV. It depends on the patient's underlying condition what kind of pressor they get though.

Dopa is typically the first line inotrope in children, my cardiac unit however sees infants to adults and dobutamine is first line for adults although i'll be honest I don't know all the reasons why.

To the OP I have unfortunately seen infants with dopa & epi infusing through a PIV and god knows what else...when they crash they crash and you don't always have time to get a central line in first thing. They do eventually try for a central line but it's more important to get the drugs in initially

[detroitdano]

If you've got an ScvO2 catheter and a Vigileo hooked up to an a-line, you can definitely titrate dobutamine. Swans are so rare for us nowadays, the above situation is our norm. They'll usually drop in an ScvO2 cath then write to titrate dobutamine for an SvO2 > 70%. The end goal is increasing perfusion to vital organs, which is reflected in that number. Then watch your Vigileo numbers for good signs like increased CO, decreased SVR, etc.

I've honestly never used dopamine. Ever. It's just a hospital-by-hospital preference I guess, but one of our ER docs basically invented early goal directed therapy with sepsis and our order set uses either Neo or Levo. We typically go with Levo first, then add Neo second and titrate off the Levo if it wasn't doing the job.

Pressors can be run peripherally. Dead patient or patient with a beatup arm, take your pick. If you've been infusing it peripherally for hours on end, someone needs to be at the bedside stat getting you a central access.

[Nurseboy1]

We often titrate dobutamine in our MICU without swans, we draw q2h SCVO2 levels and hook the patient up to the lidco to watch their CO and CI. Once we reach a stable dose then we change to q4h SCOV2 draws. If they need it we will swan them though.

Our first line pressor is levophed, however it is policy for our hospital that a central line must be placed ASAP for all vasopressors and inotropes.

[maloneys]

This is FASCINATING! I'm reading about measures I haven't heard of before. Prior to you mentioning these, I'd never heard of the ScvO2 cath and Vigileo, nor the Lidco. I'm trying to get info on these via the net. So basically, if I understand, the ScvO2 cath can be inserted through any central line or aline, then rests close to the right atrium?

Also, are the draws all done and calculated within the Vigileo, so it remains a closed system?

Re: pressors peripherally, patients can be kept on them for DAYS at our hospital.

[Nurseboy1]

So my hospital utilizes the Lidco, which plugs into our monitors and calculates the information from the A-line data, so it is only as good as the A-line.

I have worked at another hospital that utlized the vigileo, and the continuous SCVO2 is a special triple lumen catheter itself. It has the standard 3 lumens then it has a cord that plugs into the vigileo to monitor the scvo2.

In my current unit we draw the labs from the distal port of our triple lumens. We also monitor their CVPs and have standing orders for AVO2 diffs and CVPs if the patient is on vasopressors or is hemodynamically unstable.

Why does you hospital allow for pressors to be run peripherally for so long? If they are that unstable then they should have central access.

[maloneys]

Thank you, Nurseboy. Okay, so what is the difference between the traditional triple lumen catheter (central venous), and the ScvO2 cath?

Americans have the most wonderful medical technology! I'm envious of all the equipment you have to monitor patient status.

The hospital I work in now is a small, tertiary hosp. Only one doc on all night, works in the ER, and covers the hosp. This means that all are orders are received on telephone. Most docs covering ICU don't come in from 8pm to 9am. So if a patient is unstable and requires pressors, we give it peripherally. Most of our ICU pts don't have central lines, except for PICCs. Frustrating! It's always been that way and there isn't an active move to progress or change. Doubly frustrating!

[Nurseboy1]

So this is what the SCVO2 triple lumen looks like. The blue sensor gets plugged in line for the vigeleo.

I wish my hospital used this system, but we use the lidco instead or just place a swan if needed.

Which country are you in? I work at a large academic teaching hosiptal and we have an intensivist in our unit 24/7, in addition to 2 residents.

[maloneys]

Thank you for that picture, Nurseboy. So the SvcO2 can be used to monitor and infuse as well? Great!

I live in Canada, and I used to work for a teaching hospital that had 2 residents on site, for the ICU, overnight. This one now, only just hired an overnight RT, no orderly, 4 nurses for 11 patients plus hospital wide tele monitoring. Eeek!

[Nurseboy1]

Correct the line both monitors and infuses as well