gtt ???

[surething1]

when u have vasopressin running and another drip like say dobut or dopa or whatever. do intensivists or critical care docs like to wean off the other drips first and then vaso. Or do they prefer to get them off something like levophed first? Whats the rationale. Im sure there are many different situations but in general if u could try to explain this to a new grad I would be most thankful.

[BelgianRN]

In my hospital most intensivists like to see vasopressin weaned pretty quickly, generally because of it's very potent splanchnic vasoconstriction and the fact that up to now it has always failed to prove useful in reducing overall mortality etc. But despite this we use it a lot.

Reasons why we generally keep vasopressin over norepi for example would be continued uncontrolled acidosis as vasopressin remains potent in an acidotic environment were norepi loses a lot of its functionality.

Another reason why in our hospital we sometimes wean vasopressin after norepi would be severe pulmonary hypertension. Vasopressin has a lot less influence on the pulmonary artery pressure when compared to norepi.

As you can see from my post our intensivists generally won't use phenylephrine as a vasopressor and stick to combinations of norepi and vasopressin. I generally disagree with them on this as I like phenylephrine a lot as a vasopressor, but for some reason they just pull up their nose and go "nah" whenever it's suggested as a vasopressor :). Only time I've seen it used is on neurosurgical patients or after norepi, epi and vasopressin fail to produce a desirable BP... Or when I nag and nag ^^.

Keep in mind that dobutamine is an inotrope and not a vasopressor if anything it's a vasodilator. And the effects of dopamine are very dependant on it's dose where it can go from vasodilator to vasopressor and an inotrope. So when weaning these meds you'll use other criteria then just MAP.

But generally when I'm working with an intensivist whose preferences I do not know, I'll generally ask what he wants to see weaned first and if I don't get a response it's generally my own call.

[fiveofpeep]

Great post ^

[meandragonbrett]

It's a crapshoot really. It's very dependent on your patient and what's going on with them....bowel surgery? CV surgery? Neuro? Do they have valve problems? MI? Pulmonary issues? etc. Then it depends on your provider than has ordered/is managing the patient and their preference.

In my unit we generally don't titrate vasopressin. It's either on or off and we almost *always* turn the vasopressin off first even if we have to transiently turn up the other pressors before we can start weaning them.