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.
After 30 mcg I don't know if it would have done anything for this Pt.
Are you saying that after your levo was at 30mcg you wouldn't have done anything else for this patient? Don't let your experiences cloud your judgement in patient management. You might be surprised at which patients do turn around and survive and which ones don't.
Are you saying that after your levo was at 30mcg you wouldn't have done anything else for this patient? Don't let your experiences cloud your judgement in patient management. You might be surprised at which patients do turn around and survive and which ones don't.
I learned long ago not to count my ICU chickens before they hatched.
I have had patients on, CRRT, HFOV's, hyperbaric treatment for gangrene, and beyond-maxed-out drips numbering in the double digits (yes, all treatments at one time for these patients) who, against tremendous odds, pull through. Okay, not just "pull through"---they live well and prosper. They can survive, neurologically intact, although most have some residual physical issues. But they go on to have productive happy lives.
And then there are those who you think are well on the road to recovery who suddenly crash and burn beyond redemption for no apparent reason. The ones that have you thinking "what could we have done differently...?"
But to write someone off who is anuric and on 30 mcgs of levo?
Now that's just tossing in the towel before the round is anywhere near over.
No what I'm saying is Patient should have been vented, lined, and have an MD there trying to turn this patient around a nurse should NOT have to do this over the phone with a HOSPITALIST! I would have gone to charge RN and asked to try to get an MD other than hospitalist to help. I have been many times in this situation but when it gets this bad especially with a person that could have a chance to pull through you can bet that the charge nurse gets on the phone and gets an MD to come in and stabilize the patient the RN can have all the best intentions in the world but without an order from the MD you can't do much. I am very nice to the MDs but they know that I push very hard when the patients are crashing. Things that I would have done until Md comes in is if ABGs were bad work with RT to see if we could ventilate patient better, Call Md and ask for another vasopressor so he did not want Neo than what? because I would not let him off the hook. If he was septic he needed fluid resusitation, if he had CHF and no output you are in a lot of trouble. I would have to know his history, labs ect. I have titrated levophen high enough to give a zombie a blood pressure but you clamp the patient down. All I know is that the RN did the best she could I have had patients code have their chest craked open after hear surgery and be sitting in bed talking to me a week later, but I had an attending, the cardiac surgeon and two other nurses in there working together. When I worked night shift I too had nights when my patients were crashing and I played phone tag with every MD in charge of the patient and when I did not get a response I grabbed any MD in the unit I have even grabbed an ID MD and he helped me save my patient and it was not his patient he looked at everything and called hospitalist and made very strong suggestions.
If the fluids did not work then I would only titrated up to 30mcg/min then if does not work add another pressor such a vasopression, if that doesn't work add Neo-Synephrine if that does not work, dopamine then as a last resort and epinephrine drip.
You know when you have 2 vassopressors running max yes you could have added more but you need to look for the cause "why is he hypotensive" what is his H&H is he septic? If he is septic then he vasodilated and he needs fluid. You have terrible ABGs, you have no pressure, a bad pump, you have dopamine and levophed going and you gave a fluid bolus and nothing I think even if you added more vasopressors he would have died unless there was an underlying cause that could be fixed like bleeding but you were in a resusitative mode at that time an a MD should have been there.
250mcg/min levo, with 999 units/hr of vasopressin, both maxed out on pumps with rates of 999ml/hr. packed cells i dont remember how many units in 2 differnt lines using trauma tubing running in each unit wide open. Obviously pt died, it was a AAA that came in disecting and we opened it at bedside, it was a blood bath. bad situation.
Coded on the GPU, aspirated, was intubated. Had a pressure of 90/50 on the floor on 20 of Levo.
Came up to me, we placed an art line and his first pressure was 60/40. Cranked in 3L of fluid and by the time I left he was on 140 of Levo and 150 of Neo and his BP wasn't going above 80/40. He had a PO2 of 47 and a pH of 7.09 on 100% with 15 of PEEP. I threw the day nurse an amp of bicarb after the doc said it was a good call and headed out of that mess.
There was talk of nimbexing him but I think the family wanted to withdrawal care.
I'm glad I had that patient though, it's probably a fair guess he won't make it through but it reinforced a lot of the ins and outs of crashing patients for me.
I am sitting here in wonder and amazement after reading everyone's post...I have been an ICU nurse for ten years in a Level one trauma center, and I have to confess I had never seen anybody on 150-300 mcg of Levophed!!! At my facility the max is 20 per policy, and if that is ineffective, the consideration of other pressors need to be evaluated. I just hope that everyone is making sure to have an written order somewhere when a physician request those out of range dosages. Remember you all worked hard for your licenses.
I am sitting here in wonder and amazement after reading everyone's post...I have been an ICU nurse for ten years in a Level one trauma center, and I have to confess I had never seen anybody on 150-300 mcg of Levophed!!! At my facility the max is 20 per policy, and if that is ineffective, the consideration of other pressors need to be evaluated. I just hope that everyone is making sure to have an written order somewhere when a physician request those out of range dosages. Remember you all worked hard for your licenses.
Our max per policy is 100mcg/min. If we need more we just write an order and increase the max dosage. Routine use levoped 40-100mcg/min in some patients. I'm in a busy level 1 trauma ICU as well. It's always been interesting how different provider groups will manage the same patient in two opposite directions.
Our max per policy is 100mcg/min. If we need more we just write an order and increase the max dosage. Routine use levoped 40-100mcg/min in some patients. I'm in a busy level 1 trauma ICU as well. It's always been interesting how different provider groups will manage the same patient in two opposite directions.
A routine use of Levophed is 40-100 mcg/min in some patients? WOW! Where are ya'll getting this information to validate it as policy? And if you use 150 mcg/min of norepi, what is ya'lls concentration?
Our policy states a max of 30 mcg/min and if any nurse would come in my room and titrate the levo to 150 mcg/min, I would slap them silly . I have seen nurses titrate vasopressin to 0.4 instead of our policy of 0.04 units/min for vasodilatory shock...I guess they get confused with the GI hemorrhage dosing. It is interesting to see the different dosing. I am in the South at a level II trauma center
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.
Sounds like you did one hell of a job. What did the monitor show rhythm wise? Obviously you are on heparin for an acute coronary syndrome? I wonder what his EF was? Systolic or Diastolic Dysfunction? Since the cardiologist signed off, I amusing he reviewed the EKG and felt that he coded for a different reason unrelated to the heart? Sounds like a hemorrhage somewhere. H&H level? Interesting case. I wouldn't be afraid of raising the dopamine because of an Increase in HR in this scenario. MAX THAT gtt OUT GIRL! After all, you are already maxed on levophed and it seems his HR is racing fast because of the actual cause and not the dopamine. FLUIDS! FLUIDS! FLUIDS! I am very shocked by the behavior of the MD. He would be written up in a heartbeat at my facility.
Our max per policy is 100mcg/min. If we need more we just write an order and increase the max dosage. Routine use levoped 40-100mcg/min in some patients. I'm in a busy level 1 trauma ICU as well. It's always been interesting how different provider groups will manage the same patient in two opposite directions.
AFAIK we don't have a max policy on levophed. The order is routinely written (via standard computer order sets approved by our pharmacy) as "Start at _____mcg/min and titrate to (choices: MAP>____, SBP>_____)."
If you're doing a mcg/kg/minute obviously the raw mcg number without the qualifier is going to be less shocking than the rate if you're doing mcg/min. Maybe that's why some people here are waxing a bit apoplectic?
We go up when we have to and bring it down as soon as we can. And yep, people do survive (some quite well) after going through episodes where they would have died had we not kicked up the levo to what some see as nursing-license-threatening rates.
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meandragonbrett
2,438 Posts
Are you saying that after your levo was at 30mcg you wouldn't have done anything else for this patient? Don't let your experiences cloud your judgement in patient management. You might be surprised at which patients do turn around and survive and which ones don't.