CalvinJ

I get where you're coming from as I have been to the floors as well before becoming a CCRN. Personally, I don't ask irrelevant questions. I only ask questions to get a clear picture of the situation for faster management just as what BelgianRN mentioned. I'm sure that if you were to receive a patient in the ICU from the floors you would want to get details on what has happened to the patient that would lead to an ICU admission. Given the right situation I would also ask the patient's latest K+ and the one before that if the floor nurse would be aware of it. If not then I'll have to review the chart for the answer. I ask questions that I believe are relevant. The answer might help a lot in the timely management of thr patient

Id go for a manifold myself. The most important part of titrating pressors in one line/lumen is just as you thought... Not running one to a bolus and with a manifold - usually a 5-way manifold, all the drips go in as equal as how you really want the drug to go in depending on your titration so one wouldn't be flushing the other just in case you titrate one up and increasing its rate. In my experience, the runner (the fluid that runs on the main lumen and meets the other ports) is the key to effective titration. I usually run it at around 40cc/hr but depends on the patient's fluid status.

I do understand where you're coming from about tramadol however as a drip, nausea is boiled down to a minimum since its administration goes in real slow. From experience pain associated with the sternotomy is resolved by tram in 80% of our patients. Most of the pain complaints come from thr chest tubes. The tramadol drip would run for a max of 24 hrs immediate post op and shifted to orals. We make it a point that any cause of drowsiness be eliminated to facilitate lung rehab as early as possible post extubation. So there. Lol. :)

In our institution we use Tramadol as a drip for our post open heart patients. This is to eliminate the risk of bleeding with Toradol and to help decrease chances for drowsiness in patients for more chances to rehabilitate the lungs post op. We preferred it to be a drip to have a continuous dose and coverage to make up for its halflife and other pharmacokinetics. If still with pain acetaminophen IV as adjunct will be added to the regimen. But, since pain is very much relative to each person knowing that the patient has a low threshold for pain, we usually have them on Fentanyl via PCA then titrated down to the least of the patient's requirement. :)

Id have to agree with Cruffler. To understand the drips I guess understanding hemodynamics is essential. Understand the adrenergic receptors since those are the targets of the drips and compare the effect of each drug to the alpha and beta receptors. :)Basically, the drips are chosen depending on the cause of hemodynamic instability. The drip of choice would depend whether the problem is the pump or the squeeze.Basically Dobutamine highly affects the beta1 receptors which are specific to the heart so it would be the best choice for weak left ventricle patients. Levophed is is potent on alpha receptors which targets the blood vessels making it the drip of choice for sepsis or SIRS. Dopamine on the other hand, affects both alpha and beta receptors distributedly and depending on the dosage will the hemodynamics respond. Thats why they would use Dopamine in the ED more frequently because it hits more receptors than dobu an levo. Emergencies call for hitting 2 birds with one stone rather than making test diagnoses. Dopamine is a precursor of noradrenaline the body which helps in targeting alpha receptors fr vasoconstriction.Overall, if you're at the cardiac SICU then I guess you're drips would probably be either dobu or levo most usually even both depending on the patient's condition. Many post op patient are usually having SIRS so most doctors would see levophed as the drug of choice in order to help maintain a desirable BP. Hydrating would be another option just to maintain a good blood pressure as for bypass patients. For patients with underlying CHF causing poor ventricular EF, he/she would most likely respond to dobutamine more than the others in maintaing good pressures. Cheers! :)

Id have to agree with Cruffler. Basically, the drips are chosen depending on the cause of hemodynamic instability. The drip of choice would depend whether the problem is the pump or the squeeze.Basically Dobutamine highly affects the beta1 receptors which are specific to the heart so it would be the best choice for weak left ventricle patients. Levophed is is potent on alpha receptors which targets the blood vessels making it the drip of choice for sepsis or SIRS. Dopamine on the other hand, affects both alpha and beta receptors distributedly and depending on the dosage will the hemodynamics respond. Thats why they would use Dopamine in the ED more frequently because it hits more receptors than dobu an levo. Emergencies call for hitting 2 birds with one stone rather than making test diagnoses. Dopamine is a precursor of noradrenaline the body which helps in targeting alpha receptors fr vasoconstriction.Overall, if you're at the cardiac SICU then I guess you're drips would probably be either dobu or levo most usually even both depending on the patient's condition. Many post op patient are usually having SIRS so most doctors would see levophed as the drug of choice in order to help maintain a desirable BP. Hydrating would be another option just to maintain a good blood pressure as for bypass patients. For patients with underlying CHF causing poor ventricular EF, he/she would most likely respond to dobutamine more than the others in maintaing good pressures. Cheers! :)

I happened to see this and it has been like what? 4 years?! Lol. Anyway, in our institution we use weight based computations and accdg to pharmacology literature levophed shouldn't be given more than 2 mcg/kg/min but as per experience, I have never reached 2 mcg/kg/min in my titration for the usual patients. The highest so far that I have reached was 0.8mcg/kg/mun. I just had 1 patient who we gave the max dose of 2. She was terminal already and we had to max out our drips to the point where the family would reach acceptance.