drip titration resources

rhon91 · Feb 5, 2010

Ask for the unit orientation manual- meds u need to know should b in there. Good luck!

fiveofpeep · Feb 6, 2010

Thank you rhon91!

I interned there and I dont remember there being a unit orientation manual but Ill definitely ask about that on Monday. I did take home the standard procedure order forms for s/p CABGs which includes parameters for a lot of the gtts. Would the orientation manual have more than that? Im wondering if my unit even has one because I poured over alot of their random binders on my down time and saw nothing to that effect.

I saw that Marino's "The ICU Book" has a section on hemodynamic medications so Im going to read that section online tonight and hopefully it has what Im looking for.

How about any websites or anecdotal advice ICU Faqs style?

sunnycalifRN · Feb 6, 2010

fiveofpeep,

cool nickname!! there are so many different IV drip meds . . . but since you mentioned CABG patients, that's a good place to start. certainly, review the actions and parameters for all the common IV drip meds that are used on CABG's; e.g., nitro, dopa, neo, insulin, dobutamine, milrinone, and sometimes epi, levo

for sedation: fentanyl, versed, propofol

and when your patient goes into Afib - amiodarone

the art of titrating the drips is just that . . . a little of this and a little of that, one can cause the BP to increase, the other can cause it to decrease . . . and changes that you make to the drip rate will take effect slowly and when you back off, again, the effects are not immediate . . . and you always must think about the side effects of the various meds: for example, propofol, while a great sedative, will cause big time hypotension . . . so much so, that it is often given IV push to bring down the BP, if its way high . . . also, versed, at higher doses, can cause hypotension

that's why for the immediate post-op CABG's, you are usually allowed to push IV fluid within certain limits, because the fluid boluses will cause immediate BP changes, while the drip rate changes take minutes

the ICU is a very dynamic place to work . . . you probably won't start off taking CABG patients, and even if you do, you will get plenty of orientation time. you're going to have fun!! as a new grad, it's a LOT to take on, but it definitely doable. Good luck!!

fiveofpeep · Feb 6, 2010

Thank you so much sunnycalifRN for such a thoughtful response :) I really appreciate your time and effort!

The advice about fluid pushes working faster than drips is just the kind of stuff Im looking for. During my internship the ICU gods always knew when to increase and when to hold back and when to hand pump in albumin and when to just rely on the drips. I always worry that I dont have the experience to know so what if I hold back and my patient tanks or I increase their drip too zealously and then their bp is too high or their bsg bottoms out.

Do you think if I look at the half life of each med then I will have a better idea of saying "well, I just upd the drip 5 minutes ago and it takes about 10 minutes to kick in so I should wait a while to see if it works before I up it again" ?

By the way, "The ICU Book" is a Godsend! It definitely had the kind of information I was looking for to help you know the appropriate use for each drip. Like I always thought dobutamine was awesome for cardiogenic shock but according to the book it increases myocardial oxygen demand without a sufficient decrease in afterload so it isnt so stellar on it's own as I thought it was. I think I just need to commit this stuff to memory so I will be able to apply it in the field.

Thanks again :)

sunnycalifRN · Feb 6, 2010

You're very welcome. The half-life of the drugs isn't really that important because, remember, the drip is still running . . . the half-life only is important when you stop a drip . . as in, when you're trying to let the patient wake up for possible extubation.

It sounds like you are very motivated; you'll do fine. Just watch and listen to your preceptor, listen to ICU rounds, and assess and re-assess your patient(s). Best of luck to you.

fiveofpeep · Feb 7, 2010

that makes sense about the half life :)

thanks again :)

fiveofpeep · Feb 15, 2010

so I had my first day of work and I experienced one of the same problems I was fearful about. this little old man had sick sinus syndrome and rapid cycled between 30bpm-150+ and he was waiting to get a pacer. he was never symptomatic but I just hated the whole situation.

so we were controlling it with an isoproterenol drip and while my preceptor was on lunch I conferred with the charge and we both agreed to take it down an increment since now he was sustaining 150+ for about five minutes (but still not symptomatic, which was why I was leary to turn it down). So after I do it, he has exacerbated tachy-brady and has loooooooong panic-attack-inducing sinus pauses that stretch across the whole screen. so I just turned it back up. this all happens within minutes.

eventually the cycling got under control, but it was still pretty bad throughout the shift. Now I feel even more insecure with drip titration aggh. my preceptor didnt really brief me on the situation but just kept repeating that the charge nurse made a bad decision (ouch). so I didnt really learn much from it.

It was confusing too because he said he wouldnt have done that but then later he did similarly when the pt had sustained tachy. so now I dont really know what to do in that situation. I definitely know that if I werent precepting, I would have been on the phone to the doctor when those pauses showed up and at least covered myself.

I did assess him every time he did his tachy-brady episode and he was always warm, cognizant, with fabulous pulses, a stable bp, and no chest pain or light headedness. I guess he handled it fine, but those pauses, man. they were rough. but my preceptor didnt want me to chart this, so I just filed away that in the future, if I have a similar situation I will be charting every time these episodes happen so the court knows that I wasnt just hanging out while all this was going on.

thanks for listening. Id love to hear your advice on this :)

detroitdano · Feb 15, 2010

First problem is your preceptor and you should be attached at the hip. They are responsible for you, not everyone else while they're off chowing down on a hot dog. At my facility breaks for preceptors/orients are always together. See if that's how it's SUPPOSED to be at your place. If it isn't, it should be, and you can see why now.

A lot of times your preceptor will tell you not to chart something. Sometimes this is good, sometimes this is bad. The guy has SSS, you're going to expect him to brady/tachy, it's nothing that requires a ton of documentation, I don't make a note every time I increase someone's Levo when their BP drops out of the drip range. Within time you'll know what should and shouldn't be documented. You said you assessed him and all was well, so you were probably fine without including tons of notes for the day. But if at one point he was having CP or whatever, I think a note would be merited.

fiveofpeep · Feb 16, 2010

thank you :) yeah I think one of the biggest barriers was I had never seen SSS before so although I read up on it, the rapid cycling was scary and I didnt know if this was normal. I know it says on up to date that it happens, but it just seemed so severe. That disease is one of my least faves now. I do not enjoy watching asystole creep across my monitor for what seems like forever

Ill make a point of it to just volunteer to break whenever he does. thanks again :)

Da_Milk_of_Amnesia, MSN · Feb 16, 2010

I worked in on a CT step down before i went to a different hospital...Where I am now when the nurses see a 5 beat run of Vtach they freak out, and call the Doc and I'm like dude, chill out...call the doc when he has like a 30 beat run....Moral of the story is the more you see things and work with them the more comfortable you'll feel with it. I actually had a guy with SSS the other day and he would brady down into the 30s and everyone is like OMG ARE YOU GONNA DO SOMETHING ?! My answer: Nope. He's stable, his pressures are fine and he's asypmtomatic. If it aint broke, don't fix it, AND treat the monitor not the patient. Yea sinus pauses/ arrests look scary but if he's stable and he's asymptomatic and then just watch him and see what happens.

Also when it comes to charting you have to pick and choose what you're going to chart. you have to find a 'happy medium' between writing too much and screwing yourself or writing not enough. As detriotdano said, You dont have to make a note every single time you up a pressor or decrease it. You'd never stop writing. Titrating drips is something that comes with practice. The more you work with the medication the more you know what they are going to do to your patient. I know propofol is gonna bring my BP down a bit, and i know that Cardene is gonna only touch my BP and leave my HR alone for the most part, etc etc. It all comes with EXPERIENCE which is (sorry to say it) something that you don't have at this point, but you will soon. Be a sponge, listen and ask questions, and when the feces hits the oscillator learn how to keep your cool and not freak out.