Newbie here: Starting rate for certain IV meds and where to review

[Sara Tallin]

Hi there! 

I have a few questions for you experienced nurses:

Starting rate and dose: I know that there are orders for each med that indicates the start rate and how much to titrate by. However, I've been in situations (usually urgent) where I'm asked " How much do you want to start this Levo or Prop at ?" And as a new ICU nurse I'm scrambling for the response because every patient is different. The meds we use a lot are Levo, Neo, Prop and Fentanyl. Could some of you share your experience as to what you start at if it is different from what the start rate is on the order? Also, I've been told once " oh the way you titrate is weird". I have noticed that nurses titrate differently even though the parameters indicate to go up by 5 or 1 McG. 

Is there a website out there that you recommend where I can review some items at home which could be as simple as starting an Aline and intubation? Often times during training things get hectic and it feels as if it's the worst time to be training because I'm being told various things to do quickly. I'd like to stop and review things slowly. Is there a website that helps with these processes? 

Platelets: I know this will be given a ton but we haven't yet. How do you set this up? Is it given as a primary or do you hang it as a secondary with NS to flush. I don't believe you use the blood tubing for this. 

Thank you! 

[JBMmom, MSN, NP]

If you're the bedside nurse, who is asking you what to start an infusion at? Is it another nurse or is someone else involved? Are there providers in your unit all the time? This can be a tricky thing and mainly comes with time and experience. In my unit we don't have providers after 5pm generally. There are hospitalists available in the hospital, but not always in a very timely manner. So on evenings and nights we're sometimes left to start things like pressors, or manage an intubation, without a provider on hand. Our general order for levophed is to start at 2 mcg/min (not weight based in our hospital), and then titrate by 2 mcg. If you have an A line, you can titrate every minute, if not you're stuck with titrating by cuff pressures and I won't cycle more often than every three minutes. You're never wrong to follow the administration instructions, but clearly we have all deviated in case of an emergency. If my patient's pressures are 50s over 30s, I'm starting closer to 10 than 2 (our max is 60 mcg/min). My thought process is that I can always back off, but you can't come back from dead.  

Neo is started at 20 mcg/min in my unit, it's generally not our first line pressor so it's usually started at that dose. If levophed is contraindicated for tachycardia or another reason, you might follow a similar approach to levophed.

Propofol can be tricky. The rate post intubation depends on a few things. Was the patient agitated prior to intubation? Is there a chance that they are paralyzed without adequate sedation? Sometimes patients are intubated with a push of propofol and then paralyzed with succinylcholine or rocuronium. Well, in the absence of a propofol infusion, within a few minutes you've got a paralyzed patient who isn't appropriate sedated, which seems horrifying to me. In that case you're likely to see hypertension and tachycardia, but not always. And then you have to remember that propofol will tank your pressures in certain patients so if your patient was hypotensive prior to intubation, you have to be careful with the initial infusion rate. If you have plenty of blood pressure after the propofol bolus for intubation and the patient was awake and alert, or agitated prior to intubation, you might start up a little, say around 15 mcg/kg/min. But if they were pretty altered or sedated prior to intubation, you might be able to start at 5.

And the adjunct infusion like fentanyl, versed, precedex, etc is going to depend very much on the situation. If your patient has no reason for overt pain you may not add anything else. If there's a suspected pain source like post surgery, you're probably going to start fentanyl at 20 mcg/hr. You should have PRN doses and ideally spot PRN doses rather than infusion could keep your patient ideally sedated with appropriate pain control but not unnecessary sedation. It's always a balance between appropriate sedation to maintain comfort and safety and not oversedating which is also not good for the patient. 

As for platelets, we hang all blood products on blood tubing at my facility. They fly in pretty quick, 15-30 minute infusion. 

[MaxAttack, BSN, RN]

I use the ordered start rate as my basic guideline but take the individual situation into account. All else being equal If I'm starting Levophed for a SBP of 80 I'll start at the ordered rate. If it's 70 and dropping I'll be more aggressive and double or triple the start rate.

Titration is the same - the ordered rate is my guideline and what I like to stick to but sometimes the ordered rate is too strong or not strong enough. Eg If I'm going up by the ordered rate on my Levophed but the pressure isn't really budging I'll start going up quicker (eg going up by 4 mcg instead of 2 mcg). 

Platelets go through blood tubing in the hospitals I've been at and seems pretty standard but know your own facility. There should be hospital-specific policies and procedures that you can reference. I actually like just browsing through these.

AACN has a skills book that isn't bad to have and read through ahead of time.  ICUFAQS.org has a lot of information on it as well. There's even some Youtube videos out there.