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.
Specializes in Trauma ICU, Surgical ICU, Medical ICU.
There are so so so so many things wrong with this. Was anyone helping you at all? Anyone with any experience would've been able to assist you. A high dose of levo is the least of the problem.
Is "through the roof" a valid response to this question?
We go as high as we have to with levo. We add vasopressin empirically at a rate of 0.04 units/min after we hit twenty mcgs on the levo. Other issues are addressed, of course---they're intubated, lined up, swanned (though less frequently than in the past), often end up on CVVHDF, and are the classic very sick ICU patient.
I have had massively septic patients on as high a rate as 200 (yes, two hundred--not a typo) mcgs/min and have had them live---and really live. Alive, extubated, kidneys working again. LOL---back to asking for another pillow and the remote for the TV. It's rather wonderful. :loveya:
We almost never use neo except in immediately-post-surgical patients (anesthesiologists seem to love it) or patients who become hypotensive while receiving Interleukin 2 therapy (pressor of choice with those patients, according to our oncologists). We do levo first, add vaso, then epi if we need a third pressor. Rarely dopamine unless HR is also low---too arrythmogenic.
Sorry I don't have the time at the moment to read this whole thread so maybe I've just repeated what others have already said but I thought I'd toss this out as an "IME" post.
This was posted quite awhile ago. I just saw it due to new responders. I have to agree with PiPhi20004, there was alot more to question here than the max levo dose....
If you want to talk or clarify things, you can PM me.
I've had some patients who I've titrated up to only 18-20 mcg/min without any real change in pressure. I've also had patients where I've titrated up to 30 mcg/min and had increased pressures. It depends on the patient and what's going on. If all the receptors have already been hit then it's time to switch to a second pressor. Since we also run it in mcg/min instead of mcg/kg/min it's possible that higher doses could work in a larger patient (if my thinking is correct here...).
Oh, and don't even get me started on dopamine. I hate it...grr... why do so many people still use it as a pressor? Worthless, arrhythmia and tachycardia inducing drug... heh. Sure the pressure is higher, but the patient's heart rate is in the 140s. Remember Starling's curve? I want to say that so many times to people who start it as a pressor.
Yikes! That sounds like a rough day. However, where were the other nurses? Just two weeks ago I had a new post code with sbp in the 50s and I had another nurse (teamwork!) help me out with her. We wound up maxing her on levo, dopa, neo, vaso, and epi and still she was tanking. What the older nurses have always drove home with me is to give enough fluids with the pressors. In other words, the pressors won't work well enough if there isn't enough to "press". And did you say that the pt was on cpap/ bipap and not tubed?? There seems to be a few loose ends missing that I don't think you were responsible for.
I've gone up to 100 a few times (they both ended up dying- that high you're just buying time for family to get there). We add vaso at a sepsis dose (0.04) generally if we're up around 50 of levo and not seeing any changes.
That's ICU for ya...you get a pt on 6 of levo and 4 of dobutamine and around 0300 you're down to 2 of dobutamine and 3 of levo and you think "Oh, man, I can wean these off by the end of the night, their pressure and cardiac output are great" and about oh, 0430 they start tanking. That's what you get for thinking!!!!
I've only been in the MICU since June and have seen Levo before, but it's usually very low doses (5-20 mcg) and they're off it by the end of my shift. The past few nights I had a septic patient who I admitted on 12 mcg and when I left yesterday she was on 35 (had it up to 48 at one pont) and 0.04 unit/min of vaso.
She got 8L of fluid in 2 days (4L NS, 4L LR because she was so acidotic). She went oliguric, CVP was in the 30's. Potassium was 5.9 and creatinine 3.7 up from 4.7/2.2 the morning prior when I admitted her.
I hope she makes it as she is A&Ox3 and was a really nice lady. I'm kinda excited to go back in and see how things went, if she got intubated or got dialyzed, etc. Her condition is/was very serious but it's interesting to see how sepsis really hits people and watch them the progress through the stages. I'm a physiology nerd and was hitting up UpToDate and playing around Google all night figuring out all my unanswered questions.
what was your patient's Crit? Did the patient possibly need some units of blood and more fluids? If not possibly a contractility issue and may have benefitted from doubutamine? I the ICU where I worked when there is a falling blood pressure we always started with preload, then afterload then contractility. So fluids first, then pressors, then dobutamine. If none of this worked then it must have just been the patient's time. Don't be so hard on yourself. You did all you could with the resources you had and I'm sure you learned a lot from this experience and will be a better critical care nurse for it.
It appears you did a fine job with a difficult situation. I have been in the ICU for about 2 years (still new if you ask me), but just this week actually had a pt on 80 of levophed and 160 of neo and having to dopler the bp. Full code, HR in 140-180s, trach-vent. Even with a manual, dopler BP of 60/30, pt was totally with it. Sounds like a similiar situation. You do what you can, update the docs as much as possible and then chart all calls with docs.
One thing I have come to notice is that a lot of the time in critical care we are just delaying the inevitable and when its the pt's time there is not much that can be done even with all of our advances in healthcare.
Just a thought, in response to someone that isn't responsive to pressors or fluids, sometimes you may want to check their cortisol level. It is easily fixed, but if someone is in circulatory failure from or complicated by a critically low cortisol it seems NOTHING helps the BP until this is fixed...Seen this a few times. Good thing to check if your grappling. Kind of a while your at it lab, eh? :)
This patient had no pressure that is why you had no output MD said no to Neo and if you kept on giving fluid boluses he would have drown in fluid. After 30 mcg I don't know if it would have done anything for this Pt. I have titrated all my pressors to extremly high doses but it was only to keep a pressure long enough for family to say goodbye.
You could try calling pulmonoligist next time if patient is intubated. It is really sad that you don't have an attending to call. In any case you did a good job "R is for resusitation not resurection"
PiPhi2004
299 Posts
There are so so so so many things wrong with this. Was anyone helping you at all? Anyone with any experience would've been able to assist you. A high dose of levo is the least of the problem.