Dopamine drips in SNF?

Specialties Geriatric

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Hello, I was wondering how often dopamine drips are used in the SNF setting? Doc admitted a patient today on a 5mcg/kg/min drip with no orders to titrate (for renal perfusion). I was wondering if drips were even allowed into the SNF setting?? and, if so, whats the protocol? how often do you check VS? Help please!!

Specializes in Trauma ICU, Peds ICU.
It is a PRESSOR, for Pete's sake, and even if they are using it for renal perfusion (which is controversial), at 5 mcg/kg/min, there are pressor and inotropic effects. At a minimum, VS need to be done q1-2 hours, and UO needs to be looked at q4h, and they should be on a telemetry monitor. I doubt a SNF can provide that level of care.

No, it's not a pressor (or an inotrope), not at that dose. At 5 mcg/kg/min you're only activating dopaminergic receptors which in theory dilate kidney vasculature, but as you point out there's growing evidence that it doesn't work.

From 5 to 10 mcg/kg/min it also activates beta-1 receptors and is a positive inotrope and chronotrope. It doesn't become a pressor until >10 mcg/kg/min because it's only at those doses that you start to hit the alpha-1 receptor.

That's why when we're using dopamine as a vasopressor/inotrope, and titrating down in response to more adequate blood pressure, we just turn it off when you get to the 5 mcg range, because at that point it's not doing anything for your BP through either increased vasoconstriction, contractility, or heartrate.

It's probably inappropriate to have in an SNF d/t the lack of training and the therapy being (probably) ineffective, but it's far from unsafe at that dose, and wouldn't necessitate more frequent VS or telemetry.

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Specializes in multispecialty ICU, SICU including CV.
No, it's not a pressor (or an inotrope), not at that dose. At 5 mcg/kg/min you're only activating dopaminergic receptors which in theory dilate kidney vasculature, but as you point out there's growing evidence that it doesn't work.

From 5 to 10 mcg/kg/min it also activates beta-1 receptors and is a positive inotrope and chronotrope. It doesn't become a pressor until >10 mcg/kg/min because it's only at those doses that you start to hit the alpha-1 receptor.

That's why when we're using dopamine as a vasopressor/inotrope, and titrating down in response to more adequate blood pressure, we just turn it off when you get to the 5 mcg range, because at that point it's not doing anything for your BP through either increased vasoconstriction, contractility, or heartrate.

It's probably inappropriate to have in an SNF d/t the lack of training and the therapy being (probably) ineffective, but it's far from unsafe at that dose, and wouldn't necessitate more frequent VS or telemetry.

I was always taught that the pressor/inotropic effect of dopamine begins in the 3-5 mcg/kg/min range, and that the renal perfusion dosing is at max 5 mcg, typically given more at 2-3 mcg. It is a low dose pressor effect, but it is still there. There are a lot of drug books out there and they don't all say exactly the same thing.

I have seen from repeated clinical experience that you do indeed get a higher blood pressure, increased cardiac output, and a higher HR from dosages at 5 mcg/kg and even below that. Our OHS patients routinely come out on dopamine at 2-4 mcg for pressor and CO support. I have had many patients even be tachycardic and hypertensive on a supposedly low dose of 3-5 mcg/kg/min, and then you shut it off, and it miraculously resolves.

Have you ever actually worked with the drug? I have worked in various parts of the country, and one place in a unit I was at, they ran DA up to 20 mcg/kg and just tolerated tachycardia to the 130s often. I was always told that 5 of dopamine is just a spit and didn't do anything as well at this facility. Then I moved to the Midwest, and much lower dosages that still had desired clinical effects (increased B/P and CO) were used that didn't exacerbate tachycardia nearly as much. Now where I practice it is actually frowned on cranking dopamine up to the max dosage because of those effects. Typically we will add a pure alpha (like neo) instead if we need to for B/P support as it tends not to increase HR as much.

Drug books are important and good initial guidelines but especially in the case of dopamine, I have found them to be lacking. I personally feel there is a gradient at which the renal dose effect declines and the pressor effect begins. To say that it is exactly at 5 mcg/kg for every individual is misleading and I have not found it to be clinically accurate.

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Specializes in multispecialty ICU, SICU including CV.

Just checked the drug book I have, Mosby's 2010. Adult dosing for "shock" ranges from 2-10 mcg/kg/min. That implies that whoever wrote this book believes that the pressor effect begins at 2 mcg. There are no listed doses for renal perfusion (?because of the controversy surrounding whether it really works?) although it says it has renal perfusion effects at "low" doses. If shock dosing to them is 2-10, I would think "low" means more like 2-3 tops.

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Specializes in geriatrics,wound care,hospice.

No policy? No monitor? NO WAY! Somethin's gonna give on this one...Better keep those vitals and documentation up to the minute,and MD on speed dial...........Good luck!

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Specializes in Gerontology, Med surg, Home Health.

I've worked on many sub acute units...at no time would we have entertained IV dopamine. We don't do IV Heparin, Lasix, solumedrol, or IV narcotics. We don't have staff in sufficient numbers to monitor these patients.

PS. I'm the DNS. It's MY license on the wall. If the staff can't safely care for a resident, we won't accept them no matter what corporate thinks.

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I've seen it before..we would take anything. Wasn't pretty. We can't even get routine vitals and weights done on heathy folks.

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Specializes in PICU, NICU, L&D, Public Health, Hospice.

I work with SNF staff frequently. I often have to schedule prn meds to insure that my patients are comfortable. I frequently have to weigh patients myself. Too many facilities cannot even keep track of the bowel habits of an incontinent patient.

I cannot imagine what would possess a DON to agree to take such a patient and then not even prepare the staff for the care...

This is a huge liability for the facility...and for licensed staff caring for this patient.

Is this a geriatric case? DNR?

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I've worked on many sub acute units...at no time would we have entertained IV dopamine. We don't do IV Heparin, Lasix, solumedrol, or IV narcotics. We don't have staff in sufficient numbers to monitor these patients.

PS. I'm the DNS. It's MY license on the wall. If the staff can't safely care for a resident, we won't accept them no matter what corporate thinks.

I'm going to guess that is a regional thing, here in the PacNW on the subacute units I've worked we've done all those meds (and more) going 10 years. I have seen Dopamine used on sub-acute units but only in patients who were, in effect chronic. Chronic as in no titration and a track record of no undesired side effects.

Perhaps the units I've worked in aren't the norm in that they had highly experienced, well trained staff and better ratios then many of the med-surg units I see discribed on this bb. I'd go back to it in a heartbeat if I could walk.

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Specializes in Legal, Ortho, Rehab.

No, no, no not in a SNF!!! Not the norm at all. :redlight:

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Specializes in Gerontology, Med surg, Home Health.

We sent a resident to the hospital yesterday afternoon. He couldn't maintain his sats above 79. They admitted him to the CCU. They called today and wanted to send him back...from the CCU!! I said no. Jeezlies Peezlies at least wait till the poor guy is stable before you ship him home.

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