Titrating drugs: dosages or CC's

[dorimar]

I was hoping for some input on the way things are being done elsewhere. I was always taught that you must know the dosage your patient is on of any titratable medication. This is common sense as far as i am concerned (ie max dosages, side effects and complications of drugs at certain dosages, and just to have an overall picture of how the patient is doing-- ie yeah his map is 70 but he's on 30 mcg of levo and 100mcg's of neo). I have always known my dosages even if i had a pump that didn't titrate by dosages and i had to tirtate by CC's I knew my constant , so every change, i knew my dose. Gees when i first started nursing we always had to calculate it because there was no such thing as dose calculator pumps. I am at a new job in a level 1 trauma teaching facility. I am shocked to find that most of the nurses have no idea the dose of their titratbale drugs, and many are even CHARTING their titrations by cc's (ie: Neo increadsed to 14 cc/hr). I took care of kid the other night & His propofol was at 25 cc/hr which calculated to 67mcg/kg/min. Now i know for a fact the prior 2 nights his nurse had the propfool at 50 cc/hr because i answered his pumps more than once. That means they were running his propofol at 140 mcg/kg/min. So wrong. Just interested if this is a trend where they don't have dose rate calculator pumps.

Doris

[Pedi-ER-RN, RN]

Alot of facilities have "dummy sheets" that are printed by the pharmacy for each gtt the pt is on. That way, when you decrease the gtt by x number of cc's, you can chart, dopamine titrated down to 8mcg/kg/min (15cc). I have found this is very helpful.

[roana]

Hi Dorimar;

I don't know if you're still watching this thread but I'll answer anyway. First of all, I totally agree with you that the nurse HAS to know the dose of any drug she is infusing, period and no exceptions.

I struggled with this for a while, too, until I came upon the method that works for me. When I first hang the drip, the patient is usually crashing, so I don't bother with dosaages. First, I set the cuff to go off q 2 miniutes, then, depending on how desperate the situation is, I'll start the gtt at 2 to 1o ccs/hour and reassess in 2 min. Repeat as necessary till map >60. After the pt stabilzes, then I'll do the math. This works well with Dopa, Levo and Propofol for me. I found it saves a lot of time and trouble during a crisis because you're going to titrate to effect anyway (within reason)

Roana

[steelydanfan]

Drug dosage is calculated of drug amt vs body weight. Sometimes it is generally expressed as per age (500mg/adult, 350 mg under age 12); with more critical drugs amount is based on wt; ie mcg/kg, or mcg/kg/min when the drug is rapid acting and needs to be titrated instantaneously for effect.

The nurse has to recognize the difference, for what good would it be to be titrating a dopamine drip by ml/hr, if you don't know that the drip rate currently running is outside of normal parameters? IE drip is at 50 cc/hr, but your patients actual drug dosage is at 35mcg/kg/min, outside of dosage parameters?

The newer IV pumps will display both the drip rate and the drug rate, so you can choose to titrate the dose by rate or by dose, and the change is expressed in both formats.

Hope this helps.

[papawjohn]

Hey Y'all!!!

Back in the day, IV pump didn't calculate--nurses calculated. There were two methods that I was acquainted with. First, the calc factor. I never felt comfortable with that cause it tended to involve lots of multiplying and dividing on paper towels. The second I figured out myself.

It seems like an anachronism now, but I'll pass it on for what it's worth. First--learn the drugs that are given by MCG/KILO/MIN and those that are MCG/MIN. Then figure out what your Pt is recieving if the IV pump is set on 10cc/hr. With the basic fiqure of X mcg/min or X mcg/kg/min at 10cc--you can double it, multiply it by 10, half it--whatever--and STILL know just about exactly the Mcg/Kg/Min or Mcg/Min.

Ran to a code a couple of years ago (60yr old man still runs up stairs to code-blue!!! Does that make ME an anachronism?) in the dialysis unit. The hospital's antique IV pumps seemed to have ended up in the dialysis unit--no 'calculation' setting on the pumps. We start Dopamine. Everyone turns and looks at each other--what rate? The oldest person present (I'm older than many of my Pts now-a-days ) scratches a few figures on a paper towel and says 'start it at 23cc/hr--that's 10mcg/kg/min.'

When we got the Pt down to ICU and weighed her on the unit bed and put the Dopamine on the ICU pump, the dose proved to be 22.6cc/hr. That's how close you can get with quick calculations if you're accustomed to doing it.

It's not rocket science. Multiply-Divide and 'Bob's your uncle'.

Papaw John

[roana]

Hey cateccrn;

I kinda took it for granted you would realize I'm not gonna just set my Dopa pump for 50 cc's an hour. My little routine is just for the first few minutes of stabilizing a patient - - -if it takes longer than that, out comes the calculator. Many times I'll start the gtt at 2ccs an hour and there is no way that is going to exceed limits no matter what they weigh! If my patient is really crashing hard - - for instance barely a response to the first trial, I'll quickly figure out what the max dose is, for example, 26ccs/hr for dopa on a 76kg man. That way I know I only have to 26ccs/hr before I have to figure something else out. This saved me quite a bit of time and trouble during the period my patients are crashing. Remember, I'm usually starting with a very low dose and titrating up in small amounts in two minute intervals when pt's condition allows. I always I have always kept the end points in mind !

[twiceaslucky]

We never titrate by ml/hr, but by the drug dose.

[roana]

I guess you're not understanding what I'm trying to say. I'll try to say it a little clearer. I ALSO titrate by dose, I just don't happen to think it is necessary or important to list evey single dose I have entered on the pump while the patient is on the way to a stable blood pressure within the range specified by the drug's pharmacology. I do note when I increase the gtt by 2 ccs but its hard to find space to even chart the corresponding BP, even less that "dopamine increased from 2 mcg/kg/min to 3.5 mcg/kg/min" Once again, I'm only trying to give those that are perhaps struggling to find a way to become comfortable during those moments of crisis a way to decrease their anxiety and focus on the outcome. Its the end result that's important.

[RoxanRN]

Not to sidetrack the thread..... I chart any pressor rate changes on the VS graphic. Just a simple entry along timeline for the time changed - " ^ dopamine to 3mcg." I will have already charted the starting dose (2mcg/kg/min) and rate in my initial assessment charting along with 'see graphic for titrations.' Saves room and you can see the changes and effects without having to dig for them.

[dorimar, BSN, RN]

Hey papaw John,

Always a pleasure to get your insight and stories. Keep them coming!

[dorimar, BSN, RN]

Roana, I understood you and I do the same in a crisis when I first start a drip. I don't think cateccrn was responding to your post, but the discussion in general.

[TennRN2004]

This is where I get confused as a new nurse. When I did my preceptorship, we titrated some by the mL, and some my the mcg. There was no rhyme or reason to it! What's the norm? What would be the best for me to learn?

I always chart both. You should always always know the dose of drug your patient is on. For example, got a patient from the ER on Dopamine the other night on __ cc's of Dopa. How much is that? The max dose of Dopamine is 20mcg/kg/min. I asked the er nurse how much and she tells me "we are on roughly 10 mcgs by guestimating his weight". This is so Dangerous! It only takes 2 seconds literally with the pumps we have to program in to come up with the weight based dose and cc/hr-our pumps tell us both. When I programed the gtt he was actually running at 18 mcgs, he was tachycardiac (of course), he had a bp in the 140's, so I quickly weaned and was able to get down to 5 mcgs in a short time. It is our responsiblity as prudent nurses and patient advocates to dose our drugs correctly and safely.

[grambograham]

We use dose rate calculators. They are easier to adjust safely and can save a lot of time. This also allows you to "double strength" some medications to easily lower your fluid intake. It is important to be able to use dosages.