Just out of curiosity---how high have you titrated levophed before? History, pt in with serious health history, admitted with CHF. Coded on the floor. CPR alone brings back a rhythem I come in at 7pm to find her on cpap with an et tube placed. levophed at 30, dopamine at 5, heparin at 9 and propofonal at 20. We attempt ABGs and are unsuccesful, fighting the tube and restraints, increase the propofnal and attempt art line and picc line. Succesful. B/P systolic in the 70s heart rates in the 140s. I cant go too high on the dopamine due to the heart rate, titrate up and down and can not find a balance. I take the dopamine up to 10mcg at one point. Dr insists verbally over the phone I keep titrating the levophed to get bp systolic at the 100 range. Can not be done, I call pharmacy to question just how high I can go, am told there really is no cap?? according to my drug book 30 is range. Eventually pt put on vent, lower the propofonal to try and raise bp. I eventually titrate the levophed up to 60!!! I am so uncomfortable at the 60 range I call the Dr almost in tears--told him I feel like I am treading water and not keeping my head above. FYI I called him when I hit 50 and still had systolic in the 60s. I had the pumps concurrent with 75ns behind the dopamine and levophed. These are running into her picc.
No output in over 12 hours even though almost 2.5 liters of fluids/meds combined in. Dr made aware of I&O. Only order a small dose of Lasix. Not successful. ABG's horrible! FYI patient full code and family even after 3 in depth conversations insists on full code status. I am literally going over my algorithms in the supply room in preparation. Dr tells me to tell the family this is it, this is as high as the drips can go. Pt is 38 yr old. Finally family agrees to no code status, but want to remain where we are at, leave the et tube in and leave the drips where at, but understand we will not be giving any more meds.
The patient passed away shortly after the end of my shift, I was still on the unit so I assisted. Very sad, I felt so frustrated like I should have done something but totally felt like my hands were tied. Plus just didnt know what to do anyways---I was in contact with the ER doc and he had her tele up in er so he could watch. I had contacted primary and heart dr several times through out night. There is something really freaky about seeing an art line bp of 48/43 and a heart rate of 120.
I dont really even know what I am asking for in this post---I feel like I did something wrong, like I should have been doing more, or maybe did too much with the levophed that high. BUt i just didnt know what else to do, So all you critical care nurses, feel free to educate me. I am a new ICU nurse. The learning curve is huge. I had the nursing supervisor on my back most of the night, she said i did fine but I still feel like there was something else I should have suggested to the Drs.
I agree. After 20 mcg/min of Levophed, you're probably not going to get much more of a response from increasing the dose. You did well to keep putting the onus back on the doctor for the low pressures. 2nd guessing yourself, in my experience, is usually counterproductive. Assuming an adequate CVP, perhaps you could have titrated the Dopamine up to 20 mcg/kg/min, but adding an additional pressor like vasopressin is perhaps the most you could hope to get out of that doctor. I'm not sure what his Hx was and the cause of the CHF, but I don't think flooding him with fluid was the answer. The amount given sounds about right. With that much Levophed, the problem is clearly not that his arteries are not clamped down enough. Had anyone suggested an inotrope such as Dobutamine to try to increase stroke volume and thus increase cardiac output? Again, it sounds like you did a good job. All we can ask of ourselves is to do the best we can. If we do that, we have nothing to be ashamed of.
Whatever the case -- wet/dry septic/chf - dude needed a swan to figure out exactly what was wrong. I suggested Primacor over Dobut b/c of less side effects when he's so sick already. Probably could've used a IABP too. I still think he needed more volume....
Thanks. I agree that a swan would be very helpful. I'm glad you agree with me that an inotrope would be helpful. You are correct though that Primacor would be a better choice. The swan would tell us his SVR and if he needed a balloon pump. I thought that with red frothy sputum he might have all the fluid he could handle, but the swan could prove me wrong. Too bad one wasn't available.
Sorry for your experience, but hang in there. You learned alot from this patient, and recieved some very good advice and thoughts from the posts here.
Personally, I have worked on pt's that there was no limit to the levo. I've gone over 250 mcg/min--switched to delivering it as mcg/kg/min, added numerous pressers, inotropes, bicarb gtts, albumin, lasix gtts--even adding the lasix to the albumin gtt. Had afew pt's on two vents, CRRT with this mottley crew of vasoactive substances and afew made it, most did not. With these types of pt's couldn't and wouldn't have done it without adequate hemodynamic monitoring and a doc at the bedside.
I agree with the previous posts--good advise--was this pt wet/dry/septic/CHF--you reported to the docs and got only so far. Regarding the mode of mechanical ventilation--with a pt post arrest, deteriorating, plus this restless and aggitated CPAP just wasn't appropriate. WOB has a major impact on oxygen consumption and you started out at a dead run.
The only other thing to consider--maybe the docs knew something more and were not filling you in. Maybe they had a preconcieved point, were only going so far with this patient and were waiting for the family to come to terms. This sucks big time--leaving you at the bedside to fight the good fight, deal with the family and be left second guessing yourself. This does happen--some docs just don't feel they should be bothered when the end is iminent and the family in their opinion "just don't get it!" You get caught up in the gray zone of doing everything that you can or do you do everything that will work. They need to communicate to the nurse at the bedside giving their all, sometimes alone trying to deal with what is at hand and a family going thru the worst time of their life. What your docs should have done is to be there too.
Anyway, good post, good ideas and advice. Go on and fight the good fight Nurse!
The highest I have seen in my unit was like 100..., with vasopressin, neo, and many others....usually we are asking for something to add or something else around 30mcg....
Well, recently had a 19yr old male who coded on the floor post-op for a bowel resection. Previously healthy guy. We saved him, brought to ICU tubed, lined etc. Started Levo, added vasopressin, dobutamine, epi, propofol. Over the course of a few days levo was at 80mcg along with all the other gtts. Kidneys shut down, was not looking good. 43 liters positive, fluid was the major factor in keeping MAP of 60 BP often 60/30. Long story short, he woke up, no deficits, renal function returned, pt went home.
Our facility runs Levophed at mcg/min, where many run at mcg/kg/min. The highest I have ever titrated Levophed was beyond our formulary max of 300 mcg/min. (My Kathi White reference notebook says 30 mcg/min.) This particular patient was a "heroic efforts" scenario - a younger man (with 2 young children) who had arrested while swimming laps. He was on dopamine, dobutamine, neosynephrine, levophed, and epi. He was vented and on an IABP. From the point I got report, I knew the day would be a hectic one. I simply asked the intensivist "Do I stop at the formulary maxes, or go on to ridiculous levels?" His answer - "Do what you have to do to get his pressures up." I was beyond the max on every single drip at the end of my day. I think I was at 20 mcg/kg/min on both the dop & dob, 1500 mcg/min on the neo, 500 mcg/min on the levo, and 150 mcg/min on the epi. Night shift added vasopressin after his first PEA code. His family let him go with the second code.
I've run pressors higher than "max", usually have the doc right an order stating something like "titrate above xyz as needed", or something to that effect so that there's a record that they knew it was high and were okay with what we were doing. I have a question about something the original poster wrote:
"Then to make it even worse---when the heart started plummeting and the one daughter was up in the bed with dying parent sobbing, and pt was vomiting bloody froth around et tube, I said to daughter "Do you want me to remove the et tube?" and she sobbed yes yes yes. Then the day nurse who I had just given report to told me I couldnt do that with out a Dr order, even though family insisted. So I swing open the curtain and ask another nurse, and she agrees,. cant remove the tube, so a call goes down to get the ER doc to give the order to remove, by the time the order comes, the pt has already passed. So I felt like crap,. make an offer to remove the tube only to find out I cant."
Any RNs out there who have ever thought it was ok to pull a tube??? I'm a fairly new nurse and I would NEVER even dream of dreaming about pulling an ETT. I think it would be something like assisted suicide unless there is an order to withdraw ALL care on the pt. And even then, in my facility anyways, an RN would not do it. Maybe respiratory. . . maybe. Also, if pt was spitting up blood or anything from tube I think it might be less traumatic to leave it in place as tube removal would mean more risk for full blown aspiration. . . although at the stage mentioned it wouldn't really be an issue I guess? just a little confused about the tube pulling thing.
But to the original poster, sometimes you can do everything and more and pt's still die. Don't feel bad or that you did something wrong. Some times this job just stinks.
The highest I have ran Levophed is 250 ml/hr of quad-strength ( 32mg/250ml). I don't believe there is a "max" rate, you should titrate to effect but my experience has been is anything over 100ml/hr of regular concentration (8mg/250ml) for longer than a few hours is just flogging the patient..
before anything else, first thing to do when BP crashing is to--TURN OFF DIPRIVAN. right now the pt gagging on the ET tube isnt your priority--the BP is. you're turning up the propofol and turning up the pressors--youre see-sawing the pt.
1. this was an emergency yes? if so it must be treated like one. i dont think there is time to insert an IABP while the pt is crashing. your thinking and thus the flow of interventions should follow this train of thought. if the pressure was in the 40s this is a code (at least i would have treated it as one) especially in that you were doing everything and nothing was working and the trend is going down real fast.
2. secondly, time wasted on calling people back and forth--again, in a code, cant do this. need to get the crash cart, call for help, get your charge nurse/supervisor, and get ACLS protocol. it is better to call a code and be wrong and get embarrassed by looking stupid than to try to do things all by yourself and kill a pt (not insinuating you did, just making a point).
3. first thing i would have done was give fluid bolus. one of the basic things to treat a crashing bp. get NS and open it all the way or if on a pump set rate at 999.
4. next thing was of course titrate his pressors. highest levo for us here in SICU is around 80 (some have gone up to 100). we would also have hung neo (as high as 180).
5. the priority at this point would have been to save the pt and thus, treat his emergency sx--crashing bp. all the other stuff--fluid overload, low urine output, etc...are secondary and should have been attended to AFTER THE PT CRASHING RESOLVES.
6. if youre going to call a code, then you can get some EPI in and see how that works. also, NaHCO3 sometimes help--i have seen a doctor order 3 amps for crashing bp. next thing would be calcium chloride--1amp--which helps with the myocardial membrane ionization.
7. last stuff to check--what are the H/H? he probably needs blood, or he was probably bleeding somewhere. what are the electrolytes?
at the end of the day, pat yourself on the back because you did what you were able to do and tried to save the pt. you cared for the patient and that's worth more than any accolade. like others have said, you need to learn to let go. you need to learn to leave work at work. you cannot save everyone but you have the right mentality to TRY TO save everyone.
you did a good job. learn from it and get better. all you can really do.
Our facility runs Levophed at mcg/min, where many run at mcg/kg/min. The highest I have ever titrated Levophed was beyond our formulary max of 300 mcg/min. (My Kathi White reference notebook says 30 mcg/min.) This particular patient was a "heroic efforts" scenario - a younger man (with 2 young children) who had arrested while swimming laps. He was on dopamine, dobutamine, neosynephrine, levophed, and epi. He was vented and on an IABP. From the point I got report, I knew the day would be a hectic one. I simply asked the intensivist "Do I stop at the formulary maxes, or go on to ridiculous levels?" His answer - "Do what you have to do to get his pressures up." I was beyond the max on every single drip at the end of my day. I think I was at 20 mcg/kg/min on both the dop & dob, 1500 mcg/min on the neo, 500 mcg/min on the levo, and 150 mcg/min on the epi. Night shift added vasopressin after his first PEA code. His family let him go with the second code.
WowZAAA!
Did increasing the gtts beyond their max actually increase his BP?
When you crank up your pressors like that they usually start to lose affect quicker and quicker. I've found myself going up by 10-20mcg/min of Levo. You will see an initial effect but the effect lasts only a short period of time then you are turning it up again, and over a few hours the effect gets shorter and shorter. Basically you're just buying time for the family to either arrive or accept the fact that their family member isn't going to make it.
richard1980
56 Posts