How to Titrate Levophed?

[pi.student]

Can someone help me understand levo titrations? 

I know that levo orders will always have titrating parameter goals for example Map 65-80 and we are to titrate by 1mcg every 15-20 mins (depending on institution)

I have witnessed nurses titrate by 15 mcg when map dropped by 30, where as some nurses say I would never titrate by 15 mcg is similar situations. I am having a hard time finding literature that speaks to these cases where the patients pressor requirement increases outside of the given orders.

I would like to know if there is a general guideline that states something along the terms of...if your map drops by 5 mmhg go up by 3 mcg of levo, when it drops by 10 mmHg increase by 6 mcg of levo, ect....

or

does any data exist that tells us the expected MAP increase with 1 mcg, 2 mcg, or 3mcg of levophed... and so on? 

I simply do not want to overshoot my parameters by arbitrarily titrating when provider is not present in urgent situations. Sometimes, patients cannot wait! 

Thank you nursing community for your continued support!  

[MunoRN, RN]

It varies widely from patient to patient, it depends on how much their hypotension is beta-driven, how much the increase in afterload caused by increasing the levo affects their cardiac output, etc.

This is why orders should allow room to adjust titrations to the patient's response to those titrations.

Does going up by one mcg result in an increase of 1 mmHg or 10 mmHg?

If you've established that for each increase of 1 mcg you get an increase of 2 mmHg and you've dropped to 30 mmHg below goal, then a 15 mcg increase would be a reasonable titration.

[MaxAttack, BSN, RN]

5 hours ago, pi.student said:

 does any data exist that tells us the expected MAP increase with 1 mcg, 2 mcg, or 3mcg of levophed... and so on? 

I can't imagine there could possibly be any data like this since the needs and response not only change with each patient but sometimes minute-to-minute with the same patient.

I don't think there's a right or wrong here. For me it's just experience with the drug. Hopefully you have an aline and if not set your cuff to every couple of minutes and go up slower if you're more comfortable that way since the onset is so quick. When it's all said and done I'd rather have a patient I overshot with a BP of 156/89 than a patient with a BP of 30/dead.

[Tegridy]

On 8/11/2022 at 3:05 PM, pi.student said:

Hello Everyone, 

Can someone help me understand levo titrations? 

I know that levo orders will always have titrating parameter goals for example Map 65-80 and we are to titrate by 1mcg every 15-20 mins (depending on institution)

I have witnessed nurses titrate by 15 mcg when map dropped by 30, where as some nurses say I would never titrate by 15 mcg is similar situations. I am having a hard time finding literature that speaks to these cases where the patients pressor requirement increases outside of the given orders.

I would like to know if there is a general guideline that states something along the terms of...if your map drops by 5 mmhg go up by 3 mcg of levo, when it drops by 10 mmHg increase by 6 mcg of levo, ect....

or

does any data exist that tells us the expected MAP increase with 1 mcg, 2 mcg, or 3mcg of levophed... and so on? 

I simply do not want to overshoot my parameters by arbitrarily titrating when provider is not present in urgent situations. Sometimes, patients cannot wait! 

 

Thank you nursing community for your continued support!  

As stated before everyone responds differently. We don't really know how much a med will effect a patient. I wouldn't really fret too much about keep a specific MAP as long as its above the set bottom parameter. People's blood pressure varies all the time its hard to keep it in a specific spot. Same with antihypertensives, hence why we usually put a range and understand nurses don't have all day to sit there and play with the drip to keep it in some super narrow target area.