How high have you titrated levophed?

[racing-mom4]

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.

[Keysnurse2008]

Never be afraid to "suggest" adding another pressor. But my best advice is know your facilities policy on levo. Most places the max is 30 mcg . I have titrated up to 40....but I didnt do that till the MD physcially wrote the order and I had faxed it to pharmacy. This was just a scenario where we were keeping them alive till family arrived to pull the plug, They were also maxed out on 3 other pressors. But again...my advice is know you units policy on that drug.,...if the doc wants you to exceed that they need to come in and physcially write that order. So....know your policy on your max doseage

[richard1980]

Well. That works if you have a inotrope/pressor that you haven't added or tried already.... lol

[Keysnurse2008]

what i want to know, is why the hell was the patient on cpap? good grief. the patient should be sedated and on cmv settings. was there a resident in the unit with you? a doctor should have been present. that whole situation would not fly with me. if my patient is crumping that better damn sure be a doctor at the bedside with me. none of this calling back and forth crap.

amen! the physician should have been present. i say in situations like this....know your facilities policy on that drug...and when they are going down the tubes and the md is asking you to exceed your facilities policy of max dose on that drug he needs to be present and write an order to cover you! bc otherwise......it is your liscence you are playing with. and besides that....if you are maxed on levo, dopamine etc etc etc .......you need to have that md there trying to fix the underlying condition that is causing them to crump . usually after exceeding the max dose....you are just wasting time and postphoning the inevitable. but always....dont try and be the hero...when asked to exceed the max dose your facility has in their policy...you need to tell the dr to come physcially write an order. if he doesnt.....there is always acls if it comes to that - you can give that 40 units of vasopressin till he arrives. but....always....cya.

[Keysnurse2008]

Ps. You did fine. The only suggestion I would have is to have had the ER doc come write you an order to titrate at " X max rate". I reaD where you said you were worried you had done something wrong. It sounds like you did a good job. Just always CYA in situations like this. Patients come to us with all their comorbities, health problems , drug problems and all kinds of things that are just beyond our control. Your patient went into multi system organ failure....you immediately called the MD....and continually consulted with the MD regarding their status as the interventions were not working. Sometimes you can intervene early and "fix" the underlying issue causing them to go into MSOF...and sometimes they wait too late to seek treatment and you can not save them. Just a fact...

[metalikos80]

I've seen as much as 100mcg/min in my SICU along with other inotrop....

[nursejill155]

I work in sicu and in our hospital we titrate levo up to 1mcg/kg/min or 12mcg/ min... Keep in mind everywhere is different. Also keep in mind to suggest adding something else like vasopressin or neo or even epi... It depends on your pt. It sounds like your patient was in shock keep in mind you can't save everyone it is sad! You could have probably given more fluid but it sounds like there wasn't anything you could have done! You will see that again just keep in mind that you can always suggest something else for you patient... You are there advocate! Keep a positive attitude there is always something to learn but it sounds like you did everything you could have done! Keep up the good work

[IDoNotGiveOut]

Well first off let me say that you did what you could by keeping in close contact with the MD, maybe getting a nurse manager or supervisor would have been a good idea too, just to cya.

I think the fact that you were dealing with this alone really sucks. Personally I work in a large university SICU so I am used to having a resident available to be at the bedside in seconds, not that that helps any since they usually don't know what they're doing. But if a patient is doing that bad and I am not satisfied with the resident's orders, I can at least get a fellow (on night shift and weekends) or senior staff there (during bankers hours) if I want to. But I used to work in a smaller private hospital so I understand that it's a totally different situation when you're dealing with some elderly doc who won't come in from home and maybe an ERP if you're really desparate to have an MD at the bedside.

I guess I feel a little confused by people just giving pump rates for how fast to run norepi. I have no idea the pump rate and I don't think that's important because it depends on the concentration of the drip and the patient's weight. Personally our max for norepi is 0.2 mcg/kg/min. It is usually not our first pressor anyway, phenylephrine is since it can be given peripherally. Once they get past 1 mcg/kg/min of neo, we put in a central line. Our policy lets us go up to 5 mcg/kg/min of neo and 0.2 mcg/kg/min of norepi.

I would only go higher if it is literally a code (which it was going by the vitals you gave - than you run your drips at whatever you need to run them at, but you would also have the necessary assistance inluding whatever MD is responsible for responding to the code). We usually only go up to 0.1 mcg/kg/min of norepi and 1 -2 mcg/kg/min of phenyl. before we start vaso (0.02-0.04 units/min), epi (can't remember rates - don't use this very often), and dobutamine (started at 2-10 mcg/kg/min, can go up to 40 but have never seen higher than 20), titrated to CI which we get usually from Lidcos, and if you don't know what those are lucky you. (If you don't have a lidco then you need a swan, because dobut should be titrated to CI since that's what it works on.)

Dobut can cause lots of ectopy, thereby decreasing CI and defeating its own purpose. Also can cause hypokalemia. K should be checked at least Q4 anyway - there are a lot of tests that people have suggested, but really ABG, lytes, lactate and H+H are the main things. Where I used to work, dopamine was a first line pressor, which seems strange to me now since we hardly use it and it is only a pressor at high doses (greater than 10 mcg/kg/min). Although at low doses it is nice for the kidneys, which tend to get sacrificed when people are critically ill.

Also, fluids (NS and LR) and volume expanders (albumin and hespan) should be exhausted before the patient is titrated up to maximal pressors.

I am really amazed at some of the doses of norepi people are giving, if I am calculating right even in a 100 kg person I am seeing up to 10X our max. Not a criticism, I am just really surprised. Unless you are following ACLS protocol, these are incredible doses.

[JazzyNursie87]

As far as I know, 20mcg/min is the max. If you need another pressor after that, then thats fine. The highest I've titrated has been 16mcg.

[mnurse3139]

Highest i have gone is 90 of levo, with 400 of neo 30 of dop, and vasopressin, but i knew the guy was not going to make it, status post code, too many comorbidities, but family wanted everything, done, just document what doctors, are ordering and at what time. your charge should have been there and backing you up as she should be more experienced. You did fine, just need a little more ageing with this situations. Once your old like me, your pulse will hardly even change.

[TraumaRNkristina]

I agree with the above post. First thing i do is I look at the entire picture.

1. Hypotensive? Turn off all sedation. and cpap on an unstable pt? flip them to AC....

2. Before I call a physician i get all my facts. Decide what the patient needs and suggest. HR/sat/core temp/latest abg/latest vitals esp wbc/fluid volume status/cvp/ if possible cardiac output on vigileo. (they actually took the time to place a picc in an unstable pt? why not a central line?) This way an accurate picture can be made. A common mistake I have noticed is that so many ppl don't recognize septic shock. rhonchi with pneumonia is confused w pt being "wet" and lasix is given. Then i receive the pt with 2 cc of brown sludge. If the bp is low, never ever give lasix. Lasix kills the kidneys in a septic patient and will always drop bp. there was no pee bc she sounded dry.

3. whatever orders you want from the md, you need to back up. "this pt does not respond to levo, we need to switch to neo" "CVP is 1, febrile, wbc 20, on no abx....pt needs fluids/abx/cultured/etc" "pt is acidotic bc of pressers i need an order for bicarb" HR 140s, pressure 70's? I can gaurantee you this pt needed several liters of ns on a pressure bag. IF EF is too low however, get an order for a quality volume expander, ie hextend/albumin....blood.

4. Is this a newly onset bp? Think MI/PE/bleeding/stroke etc. Get orders to validate what you think.

5. Regardless, seems like this hospitalist is in an area he is not familiar with. (is hospitalist the same as intensivist?) If you feel uncomfortable with the orders he is giving, insist the cardiologist orders more meds. You have about 5 different pressors to work with. Always before pressors, fluids fluids fluids! Who cares if they have pmh of chf...they are intubated. Lungs are protected, focus on heart and brain. Titrate those pressors as high as needed to maintain a pressure. I have had pressors in a pressure bag. 3 min with pressure in the 40's can cause an anoxic brain injury. Honestly...if they have a change in mental status during this...or bp is that low...you have all the right in the world to start cpr. This hospitalist should be comfortable with bolus of neo, fluids, whatever needed.

6. Lastly where was your charge nurse? She/He should know these things, they are BASIC for someone who is in charge. sounds like you were all alone? you can never pull an ett out of pt wo an order, you might as well kiss your license goodbye, thats called euthenasia. you need an order from the physician to withdraw care. plus what would you do once the ett is removed? they will gurgle/spurt/etc...they need meds like morphine for comfort measures.

7. ALSO fyi sounds like you walked in on a situation where too many ppl dropped the ball. You can't bring back someone that is already "dead". I'd place the pads on that pt and hope for the best. that hospitalist needed to be at the bedside. chart chart chart, remember cover your ass.

hope that helps!

[Mommy_of_3_in_AL..RN]

OUr policy states up to 30 mcg levo, and i havent seen it titrated higher. Although i have questioned it, and was told that "the policy states that, but you do what you have to" Usually, when we get near the 30 mark, we add Neo, started at 180 mcg, and titrate accordingly. I have run that as high as 300 i think, but i have seen it higher. Usually, when we are having that much trouble keeping a presure, we turn off all sedation as well. Give ativan or morphine maybe, in low doses.

[criticalHP, MSN, RN]

This patient was obviously in shock, beyond what you could do with just levophed and dopamine. Acidosis renders the drugs ineffective; therefore a bicarb bolus-separate line of course, is in order. Next, if you are titrating one drug to a point that is beyond recommended limits consider a new drug-try to think of this before you reach that max threshhold. Often adding a second pressor, or a third can have the effect you want.

My fisrt guess in someone this age was septic shock. And in this shock state its all about giving fluid ( or blood is hct is low), then giving pressors. After about 4 hours on levophed get the patient on vasopressin. Add dopa if needed, but not if HR is already high-can cause major arrythmias.

Neo is the last thing you want for septic shock,it causes too much vasoconstriction and can increase clotting from the clotting cascade (no- I won't get into sesis pathophys.)

But really, Racing-Mom, you did all you could, and you did it appropriately. You kept the MD informed, requested new orders, and made him aware of how uncomfortable you felt-bottom line....he should have came in to see that patient-he will have to answer for that I imagine.

I still get that profoundly helpless feeling when a patient is so young, and death is so unexpected. I still second guess myself too...and its never easy to hear a patients loved ones sobbing. I can still hear my worst experience echoing in my head....not too unlike what you expereicned. Keep your chin up dear! ANd don't be afraid to cry with your patients/family--it will keep you sensitive and human.