Starting Quad Strength Drip

I don't know if the question makes sense. A lower concentration but quadruple the strength? When you say strength do you mean concentration  (how much is in the bag) or dose (how much the patient actually gets)?

MaxAttack said:

I don't know if the question makes sense. A lower concentration but quadruple the strength? When you say strength do you mean concentration  (how much is in the bag) or dose (how much the patient actually gets)?

I agree that the question is confusing, but think what the OP is trying to say is that after the infusion was started, the physician reordered it at a concentration that was 4 times that of the original order.

@JustCuriousMe, why don't you start by further explaining your question and telling us what you think should be done?

Sorry this is so confusing. I was in clinicals the other day and had a patient on Levophed with a concentration of 16mg in a 250ml bag instead of the usual 4mg/250ml. He was maxed out at on the regular concentration at 15mcg/min so they switched him to the 16mg/250ml concentration to help with fluid reduction because he's a dialysis patient. I was just wondering what rate do you start at if the concentration is higher if he is already maxed out on the lower concentration? Is there a conversion? 
 

sorry if this is confusing. I really do apologize 

So, the patient is getting 15mcg/minute and 1) this is too much fluid and 2) the BP is still not where they want it, right?

Since it sounds like you are a student, I'm going to expect you to do the math here: how much volume (in mL/hour) is the patient getting on the old gtt?

The nurse switches to the new concentration of levo.  Now, here's where I bet you're getting hung up: when we talk about gtts, we don't usually talk about them in mL/hour.  For heparin, we might say the patient is on "2250/hour" and we mean 2250 UNITS/hour. For propofol, we'd say the patient is "at 30" and we mean "30mcg/kg/min." It's one of those things that "you just know" (except when you don't because you are learning!).  For your patient, the important part is that they are getting 15mcg/minute.  When the nurse switches to the new concentration, they should re-program the pump for 15mcg/minute at the new concentration. 

You can do some more math here if you would like ?(Even without doing the math, quick reflection should tell you that this will be about 1/4 the volume per hour versus what they were receiving before.) 

Then they should titrate from there...if 15mcg/minute wasn't enough, presumably they will go up to 16 or 18.  The provider order needs to reflect this dosing range and also the titration parameters (probably SBP or MAP or both).  FYI 15 is lower than the max dose at my hospital, so I can't tell you what the "right" amount is...if they aren't getting the response they want with levo, maybe they need to add in another treatment.

Here's another thing you might or might not know: many IV pumps use drug profiles to reduce errors with these calculations.  When you're just hanging NS, you can just program it at 100mL/hour and be done, but with any other drug you can choose the name of the drug, the dose, and the concentration.  Some EMRs and pumps even work together where you can send the order from the EMR to the pump.  However, double-checking is always prudent!

Hope that helps!

The dose doesn't change. If the patient was on 15 mcg/min at the lower concentration, then they will be at 15 mcg/min at the higher concentration. All this does is reduce the amount of fluid going into the patient. Max dose is typically 30 mcg/min, so there's room to increase the dose if the blood pressure requires it. 

Same concentration but lesser volume to prevent giving too much fluid to a patient needing aggressive fluid management. Order would be the same but the pump will give the same dose of medication using less volume to achieve desirable BP levels.