Titrating drugs: dosages or CC's

Specialties MICU

Published

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

Specializes in ICU, Agency, Travel, Pediatric Home Care, LTAC, Su.

I have been an ICU nurse for over 6 years and have worked in various hospitals and different type of critical care units. I was taught that you titrate always by dosage, not by CC's. If any of my docs, came by and I told them that a pt was on 10cc/hr of nitro I would get my chops busted, cause they don't care what the cc/hr are they want to know the dose. Also, if you only chart cc/hr and not dose or how the drug is mixed that would not hold up in court. Now if you tell me that your dopamine is mixed 400mg/250ml and that the rate is 27cc/hr and that your pt weighs 79kg, then I would be able to calculate the dose out to 10 mcg/kg/min. But if I do not know what the drug is mixed in or the weight, if it is a weight based drug, then I would not know the dose. Definately unsafe. Sorry if I am rambling. Been a long stretch of days at work. One other note for new and old ICU nurses a like. I found a great Critical Care Drip Pocket Guide.

Critical Care Intravenous Infusion Drug Handbook

Second Edition

Printed by Elsevier/Mosby

Gary J. Algozzine

Robert Algozzine

Deborah J. Lilly

ISBN# 0-323-03121-8

Listed price is ~$35 I think.

The nice this is this book is spiral bound, fits nice in a cargo pants or regular pocket, and the front flap of the book, has the drugs listed alphabetically based on the trade drug names, and the back flap of the book has the drugs listed alphabetically based on the generic drug names. This is an awesome book.

Up Vote Up Vote ×
Specializes in MICU.

We have the pumps that have the drugs programmed with appropriate doses, etc. I always know and document what dosage my pts are on. Of course, I also document the mls for I&O's.

I always titrate by dosage (mcg, mg, etc), even if I end up with an annoying decimal in my input. :wink2: That's just the way I prefer it.

Up Vote Up Vote ×
Specializes in Cardiac.
If any of my docs, came by and I told them that a pt was on 10cc/hr of nitro I would get my chops busted, cause they don't care what the cc/hr are they want to know the dose.

This thread is odd. I responded a while back as to how the RN chooses to titrate-not chart. I think we all know that we need to know both dosage and volume and chart both as well.

So when I was adjusting my fentanyl yesterday, I cut the mcg in half. I now know that he is on 25mcs. I also know that that is 5cc. I just wanted to know which meds do you turn down by dose and which by mLs. I guess everybody does it differently according to their comfort, which is fine. Now I know I need to find my comfort level (which is quite a ways off BTW).

When the docs came into my room and asked me what my pt was on, I said everything in mcgs. 90 of diprivan, 50 fentanyl. They seemed fine with that and so that's what I'll say. This all must come in time---right????:uhoh21: :chair: :confused:

Up Vote Up Vote ×
Specializes in Intensive Care.

Look at it this way. You have a patient running 50mcg/hour of fentanyl which equates to 10cc/h. The next nurse you take report from says that the patients rate is now 5cc/h. What she hadn't told you is that she double strengthed the bag to lower the rate. The dose didn't change but the rate did. Dosage titrations are more exact.

Up Vote Up Vote ×
Specializes in Cardiac.

:smackingf Again, I understand that the nurse must both know and chart all meds on their pts.

I just wanted to know when a dr says go up on the propofol, do you choose to go up on the mcgs or the mLs? Or when they say titrate dobutamine or nipride do you titrate by volume or dose? I've seen both from all kinds of nurses. Some go by volume, some go my mg or mcgs. In the end off of the nurses still know what their pts are on. I just wanted to know what the normal was from you guys out there!

BTW, this happened to me yesterday. We took over a pt in the afternoon. The nurse left in the middle of the shift, and told us the pt was on 20 mcs of dopa. Then when we checked the lines, the dopa was at 10mcgs-but she didn't tell us that it was @double strength! There is a lot of room for error in a situation like this!

Up Vote Up Vote ×
Specializes in CCRN, CNRN, Flight Nurse.
I just wanted to know when a dr says go up on the propofol, do you choose to go up on the mcgs or the mLs? Or when they say titrate dobutamine or nipride do you titrate by volume or dose?

Alway start or titrate drugs by dose... never volume.

Up Vote Up Vote ×
Specializes in Cardiac.
Alway start or titrate drugs by dose... never volume.

:bow: Thank You. I just didn't know what was right. I've seen it both ways. Now I'll only do it by dose. I think others do it by volume since it's easier to chart on I&Os??

Up Vote Up Vote ×
Specializes in CCRN, CNRN, Flight Nurse.

I still have to chart volume when it comes to I/Os. Most of the time, however, I'll pick the dose (10mcg/kg/min), but run the volume at the nearest whole number (ex: 10mcg/kg/min = 27.7 ml/hr.... I'll round to 28ml/hr = 10.08mcg/kg/min). Makes the I/O math much easier. The only exception is if the patient is super sensitive to the drug or it's extremely concentrated.

I hope I'm not confusing you...........

Up Vote Up Vote ×
Specializes in ICU.

We chart the cc's for I & Os but state the dose in the nurse's note. All our docs here want the DOSE not the ml's, so you have to know your stuff. Our pumps are programmable to do all the calcs for you, so it's nearly idiot proof. We titrate by dose, not ml's. When we receive orders, they are for the dose, not the ml's. We all have to pass a gtt competency exam. You have to know how to calculate your dose. Isn't that the norm for RNs titrating gtts?

Up Vote Up Vote ×
This thread is odd. I responded a while back as to how the RN chooses to titrate-not chart. I think we all know that we need to know both dosage and volume and chart both as well.

So when I was adjusting my fentanyl yesterday, I cut the mcg in half. I now know that he is on 25mcs. I also know that that is 5cc. I just wanted to know which meds do you turn down by dose and which by mLs. I guess everybody does it differently according to their comfort, which is fine. Now I know I need to find my comfort level (which is quite a ways off BTW).

When the docs came into my room and asked me what my pt was on, I said everything in mcgs. 90 of diprivan, 50 fentanyl. They seemed fine with that and so that's what I'll say. This all must come in time---right????:uhoh21: :chair: :confused:

I'm sorry cardiac, I missed the point of your post. I was not distinguishing between titrating and actual charting. I will tell you in my practice, 99% of the time I titrate based on drug dose. Now, I know if I start a Ntg gtt at 3cc/hr how many mcgs I am at, and some of our nurses will titrate Ntg by cc. I think more than anything it's because we have a fresh heart come back that we don't want to blow grafts on with high bps, it's quick to turn the ntg gtt on at 30cc and not have to program it in the pump if you need it immediately. My practice is to set my pumps up when the patient admits so if I need my ntg/heo gtts I can turn them on a titrate based on dose-it's the safest way in my oppinion.

However, there are a few times I titrate based on cc not dose. Example is a cardiogenic shock patient on epi. When you're weaning slowly say you are at .02 mcgs, the patient may not tolerate coming down to .01 mcgs, but the pump won't let you do .015 mcgs, so I'll come down in the ccs to titrate slowly. So, if .02 mcgs is 6 cc for that patient and .01 is 3cc I may go to 5 cc, then 4 cc, then 3 cc, just so it is slow enough the patient can tolerate it because from 6cc to 3 cc may be too big a jump. Vasopressin can be the same way when you're weaning a sick sensitive patient. However, in any other drug-cardene, ntg, dopamine, levophed I always titrate by the dose.

Up Vote Up Vote ×
Specializes in Cardiac.

Thanks for your clarification. You know, I'm new and it's hard to remember everything as a new nurse.

I'm starting to feel better taking care of people, but I fear how I'll react when they go bad quickly. I know that the majority of nursing is OJT; I just wish there was an easier way to gain the knowledge! I'm uncomfortable not knowing what I should do at all times! Oh well, small steps I guess...

Up Vote Up Vote ×
Thanks for your clarification. You know, I'm new and it's hard to remember everything as a new nurse.

I'm starting to feel better taking care of people, but I fear how I'll react when they go bad quickly. I know that the majority of nursing is OJT; I just wish there was an easier way to gain the knowledge! I'm uncomfortable not knowing what I should do at all times! Oh well, small steps I guess...

You'll get there. Each day it becomes easier and easier. I honestly think the hardest part for me was distinguishing between what is a huge deal in the unit, and what it's okay to watch in the ICU. I had the mentality that everything is an emergency in the ICU, but you learn pretty quick what docs want to know about right away, and what can wait until in the morning. Always trust your gut though, if you're in doubt, never never feel bad about calling and reporting something. Use your co workers they'll be resources you can't do without.

It was also hard for me to piece that the pt came in two weeks ago with pneumonia, but now they've had 10 other complications like an ileus, acute renal failure, going septic. I remember getting report on patients and thinking good grief, how did this person admit with this dx and end up with this, this, and this wrong? You'll learn to tie it all together, that's part what makes me like unit nursing so much.

Up Vote Up Vote ×
+ Add a Comment