Starting Quad Strength Drip

MaxAttack, BSN, RN · Mar 22, 2023

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)?

chare · Mar 22, 2023

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?

JustCuriousMe · Mar 22, 2023

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

marienm, RN, CCRN · Mar 23, 2023

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!

0.9%NormalSarah, BSN, RN · Mar 23, 2023

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.

Lipoma, BSN, RN · Mar 27, 2023

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.

Editorial Team / Admin · Mar 30, 2023

I think you mean concentration. This is typically done for very sick ICU patients who require lower fluid volume intake -- typically someone in acute and/or chronic kidney failure.

You will start the drip at the same dose rate, the difference in the concentration is the amount of volume you are infusing. If the drip you are using is effective at the current dose, there is no need to titrate or change the dose when you switch to a concentrated medication.

Don't go solely based on this post because your original question is missing a lot of important data -- medication the patient is on, why they are on it, what is the rationale for the concentration change, patient condition, etc.

I had a patient who was receiving 15-20 drips, all of his medications were concentrated because we would have fluid overloaded him if we did not. When we switched to the concentrated medications, we did not change or titrate any of the doses unless indicated by his labs or vitals.