ICU clinical question

[AmiK25]

I would have posted this in the ICU forum, but this forum gets more traffic and most of the posters here either are or were ICU nurses, so I was hoping you could give me your opinions. A fellow nurse received a trauma pt. yesterday with multiple fractures, including a tib/fib. In the ER, he had no palpable pedal pulses and went to the OR. When he arrived on the unit, his pedals were audible by doppler, but his foot was fairly mottled. Anyway, the docs decided to order dopamine to keep his SBP>120 and to titrate to keep the pedal pulses palpable. The dopamine was strictly for leg perfusion...he did not have hypotension. Of course, the dopamine immediately shot his heart rate up to 140-160, despite fluid boluses and adequate sedation/analgesia. The resident then ordered levophed in lieu of the dopamine. The nurse came to me asking what I thought of this order. I felt that levo was a bad idea, given that it is 90% alpha and causes peripheral vasoconstriction. I asked the resident about using dobutamine to increase CO and therefore peripheral perfusion (we did not have a PA line or anything, so we had no idea a/b SVR, etc...). The resident said no, dobutamine will not work, I want levo. As I am a relatively new nurse, I thought I would come to you guys to get your opinions on the matter. What vasopressor would you use in this situation? Any information/insight would be appreciated.

Thanks,

Ami

[Tenesma]

Because this comes up frequently regarding dopamine (it appears everybody in the medical world loves dopamine, whereas in the surgical/anesthesia world we are hating it more and more)... here is an excerpt from a review on dopamine

There are no large prospective, randomized, controlled, double-blinded studies using renal dopamine, but there are numerous small studies with the drug in the perioperative and ICU setting.

In 1991, Swygert et al. (1) performed a prospective, randomized, double-blinded trial on 48 patients undergoing liver transplantation. They showed no benefit in glomerular filtration rate (GFR), urine output (UOP), or dialysis requirement between the two groups. They did show an increase in heart rate in the treatment group. In 1993, Myles et al. (2) performed a prospective, randomized, double-blinded trial on 52 patients undergoing cardiac bypass surgery. They saw no difference in UOP, creatinine clearance (CrCl), or incidence of renal failure between the two groups. In 1994, Baldwin et al (3) performed a prospective, randomized, double-blinded trial on 37 patients undergoing aortic surgery. There was no difference in UOP or in CrCl, but 3 of the 4 perioperative MI's occurred in the treatment group.

In the ICU setting, Martin et al (4) in 1993 performed a prospective, randomized double-blinded study using dopamine or norepinephrine in 32 patients with septic shock. They found that dopamine improved UOP in 5 of 16 patient, while norepinephrine improved UOP in 15 of 16 patients. Further, when the patients who failed dopamine crossed over to the norepinephrine arm, UOP improved in 10 of 11.

In 1994, Robinson et al (5) performed a randomized, controlled, double-blind study on 17 patients with CHF, and found no difference in UOP, GFR, or effective renal plasma flow. The same year, Duke et al (6) performed a prospective, randomized, double-blinded trial with dopamine vs. dobutamine in 23 ICU patients. They found that dopamine increased UOP, but not CrCl, while dobutamine increased CrCl but not UOP. Finally, in 1996, Chertow et al (7) published a retrospective study of 256 patients with acute renal failure who received dopamine with convential therapy or conventional therapy alone. They saw no difference between the two groups with regard to survival or need for dialysis.

do you still want to use dopamine??? i think a lot of critical care medicine is practiced in ignorance, and every so often there needs to be a critical (no pun intended) review of how/what/when/where we do things... patients lives and limbs are at risk :)

[Diprivan/Vented]

I always try not to use Dopamine myself unless the pt is brady. I prefer levo as the pressor of choice. I had a pt with bleeding (somewhere in the gut, I would guess) for 16 hrs the other day. Even though the pt's BP was stable (map of ~65), I knew she was bleeding, so I put her on levo, whereas all the other nurses had tried to wean her off it. My rationale was that since she was bleeding, I'd just go ahead and tighten her up. But I was a bit afraid that with the increased BP, that might cause her to bleed more. I discussed my idea with the doctor, and he and I agreed that we'd just use levo to clamp her off. Obviously this will only work temporarily, but my objective was to keep her alive for my 16 hrs. There's no way I could fix her with just 16 hrs of work. Pt has renal failure, respiratory compromise, hepatic failure, pancreatic failure, and immunologically compromised with chronic hx of hepatitis, and she was beginning to have clinical signs of sepsis. Anyway, at the start of my shift, the H/H was 10.4/30. At the end of the shift, H/H was 10.3/29. Not bad, eh? I pretty much coasted with her, whereas all the other nurses were busy giving blood, and looking back at the previous shifts, she was losing about 200 cc's/8 hrs through the NGT, which was on LIS. I lost maybe 50 cc.

Original thread: Why didn't the doctor put the foot in ice? Maybe use some nitro for peripheral dilation?

[jewelcutt]

Surgical HRT RN, I agree totally with your response. When reading these replies I immediately thought of NEO, but laughed out loud. Giving Levo to a pt with a mottled foot and decreased pulses is absolutely ridiculous. I would have called the surgeon myself and just wrapped a warm towel over the foot to increase perfusion. Even a pressur of 90 should be enough to sustain adequate perfusion to his limb. If you're treating hypotension I wouldn't even be worried about his foot but his hemodynamic status and perfusion of his brain. What about fluid since he's a trauma pt?