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'm only new in ICU myself and have never had an experience like yours. It sounds like you did all the right things, and you seem like an excellent ICU nurse.
The only thing I questioned was the fluid - only 2.5L in 12 hours, or 2.5L during the code? If it was over 12 hours, I wonder whether some fluid resus might have filled the tank, so to speak, giving you more to play with to achieve a higher systolic.
As to levophed, the highest rate I have seen so far is 32ml/hr of quad strength, which is 8mg in 50mL.
Wait you mean 8mg in 500ml of D5W rt??!!! When would you ever mix 8 in 50 ml?? Just curious Ive never seen that before~!
Was vasopressin on board?? What was this pt's CVP reading? I know this pt prolly had more problems going on than intravascular hypovolemia but I dunno if the doc should have given lasix, with a crappy BP the kidneys are not going to put out squat, I think maybe the pt needed more volume and vasopressin. But I was not there that night and it sounds like you did a good job. What was the pts history and what did they come in to the hospital for if u dont mind me asking.
I have use vasopressin a lot to decrease the amount of levophed used, successfully in a lot of patients. I knowthe doctors I work with don't like using high doses of levophed to potential SURVIVORS because of the peripheral damage it can cause.. but is ok with a last stitched attempt for survival. I also agree that more fluids should have been tried-- even though they are a cardiac patient, increasing pressors with no positive change to BP is a good reason to try more, fill the tank like another said. Its really no hurt at that stage of the game. I also question the lasix.
Its always hard to see someone die especially when you aren't confident with what happened, you did the right thing and are talking about it.. keep talking about it, too. You did what you were asked, you cannot do any more than your best, remember that!!
It just blows me away to read what nurses are writing here.. 100mcg + of Levoped is really negligent practice no matter what a doctor tells you.. you have nothing to back you up... sometimes perhaps the tank is empty so no matter how much you squeeze it you are not going to get an adequate BP.. perhaps an inotrope is needed etc.. giving super high dose pressors has been proven to be detrimental to patient outcomes... in our unit 30mcg is the max .. a good clinican is more comprehensive in approach than just titrating up and up and up.. furthermore MAP should be used as guidance for titration and not SBP..... im dissapointed in this age of evidenced based practice and patient safety that nurses would go along with this.... NOT in my unit !
That's the best way to think of it-- preload, afterload, contractility-- EXACTLY how things run where I work. Fill it, squeeze it, then pump it more to get what you want... perfect! Glad you said it like that!! :)
It just blows me away to read what nurses are writing here.. 100mcg + of Levoped is really negligent practice no matter what a doctor tells you.. you have nothing to back you up... sometimes perhaps the tank is empty so no matter how much you squeeze it you are not going to get an adequate BP.. perhaps an inotrope is needed etc.. giving super high dose pressors has been proven to be detrimental to patient outcomes... in our unit 30mcg is the max .. a good clinican is more comprehensive in approach than just titrating up and up and up.. furthermore MAP should be used as guidance for titration and not SBP..... im dissapointed in this age of evidenced based practice and patient safety that nurses would go along with this.... NOT in my unit !
Where is this evidence based practice you speak of? Up to date says 8-30mcg/min is the "usual range" but does not give a maximum. Up to date goes on to say ACLS range 0.5-30mcg/min, but also gives an "alternative weight based dosing" of 0.01-3 mcg/kg/minute. For a 100kg patient that is 300mcg/min. negligent practice really?
I haven't seen much effect past 40mcg, but at that dose we add vasopressin or neosynephrine (and usually already have dopa and fluid challenges). I know that's a lot lower dose than I'm hearing.... but it's generally worked. Those that have died, coded from cardiogenic problems. At a certain point, it seems like you've constricted everything peripheral and used up the function a heart has. Pounding the heart more doesn't seem to get me much effect. But... reading through this thread has changed my mind some. I'll have to consider being much more open to higher doses. Thanks to all you who responded.
Last high dose I saw was 130 mcg/min on a septic patient who was made DNAR and the family was dragging their feet about a terminal wean. That dose kept him about 50/30 for nearly 2 days until they finally shut everything down and he went fast.
The other day I ordered the Levo at 50mcg on a patient with a ruptured thoracic aorta... It bought us time for the family to get in... usually however, once its at 10mcg time to add a second agent and I'll stop at 20
The other day I ordered the Levo at 50mcg on a patient with a ruptured thoracic aorta... It bought us time for the family to get in... usually however, once its at 10mcg time to add a second agent and I'll stop at 20
Why stop 20? personal comfort or literature based?
caitiecait
91 Posts
Wait you mean 8mg in 500ml of D5W rt??!!! When would you ever mix 8 in 50 ml?? Just curious Ive never seen that before~!