Titrating multiple drips

[Good Morning, Gil]

So, I am a new nurse and new to the MICU. I love it so far and am starting my 4th week of orientation tomorrow. I have learned a lot so far and have had a good variety. However, I have had patients on 1 drip at a time, usually levophed for sepsis, but I have not had patients on 2 or more drips yet. (and have learned how to scribble things down on my little notepad b/c there's usually not time to chart right away lol). I read the icufaqs.org site on pressors and have a better understanding of ones that I have not encountered yet, but I think I really just need to study a good old fashioned drug guide, as well. My question is: how do you know how to properly titrate multiple drips? I'm so inexperienced at this point that I don't even know if this is a legitimate scenario or not, but say my pt is on levophed and neo at the same time? My understanding is that these have a very similar effect, so do you titrate the neo up first since it is less likely to cause tachycardia in your pt (more gentle than levo?). And if your pt becomes too tachy, titrate levo down, neo up? And, the docs would def. just try one drip first, right? If one drip doesn't work very well, why would adding one with a similar effect make any difference? I have only worked with 2 different drips so far. (levo and cardene). (I was surprised at how quickly cardene brings the pressure down, wow!).

In the MICU, how often will I have pts on multiple drips? Is this more of a CVICU thing? I will be asking my preceptor tomorrow, too. Is this just something that comes with experience, and I need I need to be patient? I just know I have a limited time on orientation, so I need to soak up as much as possible.

[hodgieRN]

You will need to titrate multiple gtts at the same time in your unit. The best thing is time and experience. When I first started, I had to look everything up. After a while you learn how things work, what has side effects, what to turn up/ down, which gtt is best. For low BP, what works...Levo, Neo, dopamine...they each have raise BP but have their differences. We used to never use Levo. The saying was "levophed, leave em dead" because it was a considered a last ditch vasopressor, but that was when we used dopamine for everything. Now, Levo is considered a great gtt b/c dopamine cause increased HR. You have to use them alot to understand their potency which is probably the big thing. Neo you can go up 20, 40 mcg but with Nipride, a change of just 0.2 - 0.3 can cause the BP to drop and then you have to pick 0.25 or 0.28. After time, you'll be a master! Never be afraid your co-workers for advice.

[Good Morning, Gil]

Thank you! I do have a card that has all of the drips, dosing ranges, and ones that have specific guidelines, like amio use filtered tubing, and certain ones that have specific titrating guidelines. It really is just going to be experience that helps me understand them. Now that I have worked with levophed twice, I feel like I can manage it, and cardene was an easy one b/c it has such specific guidelines. I guess it really is subjective, too. 2 different nurses are going to titrate their drips slightly differently, but as long as the same result is achieved, I guess that's what really matters! And, just really being aware of the side effects would be just as important. Oh..I will def. ask for help if I am unsure. Thanks again! I can't believe how much I've learned in just over 3 weeks!

[Carrig RN]

One of the big differences between neo and levo is that neo can cause a reflex bradycardia. Often we will switch between neo to levo if our patient experiences this. The most important thing to remember is to give your changes time to work. Some people do not react to drugs as quickly as others and you keep titrating up and all of the sudden your patient's systolics are in the 200s. And some people are extremely labile in how they react, some will be tolerating a dosage fine for hours and suddenly BP will drop or increase within seconds. You'll get to know how patient's with different diagnoses react to certain gtts as well. I've been an ICU nurse for just over 6 months, I've learned so much, and I'm learning more every shift. Just never stop asking questions.

[Good Morning, Gil]

Thank you, Carrig RN. I didn't know that neo could cause a reflex bradycardia. This is why I will be studying these drugs some on one of my days off this week. Having that knowledge will help some when I use them for the first time, but still, not the same as experience. I definitely won't be stopping my questions any time soon haha. Thanks! Hope you're enjoying it!

[meandragonbrett]

You really learn how to titrate multiple gtts based on experience. There really isn't another way other than knowing your pressors, what receptors they act on and the actions of those receptors, etc.

[aCRNAhopeful]

Learn the differences between the pressors and how strong of an effect each one has on each sympathetic receptor. There are charts that show a representation for of this for each pressor on each receptor and you can see the comparison. That's the absolute key part of understanding why you would want to titrate one gtt over another. As you mentioned in your post, CVICU deals with this a lot as you look at the swan numbers titrate gtts to CO or BP, or maybe to decrease the SVR to help your CO and it's a cool balancing act. With MICU pt's that probably don't have swans and stuff think about the mechanism of each receptor and what effects the patient would benefit from vs which would be harmful (HR would be the easiest example).

[hodgieRN]

Also, never be afraid of picking an in-between number. You will learn intervals like 5, 10, 15 mcg but sometimes, picking 8 or 9 mcg can be just right. Another big thing is picking how fast to cycle the BP cuff. If you are in a situation that BP needs to up quickly, think about cycling the cuff every 5 minutes but as carrigRN said you have to give it time to work...cycling it often will give you a sense of trending. Once its were you want it to be, cycle it every 15 minutes (i think this is the usual cuff interval with pressors). The best is when you have an a-line.

[flo136]

I agree with the other posts about experience guiding inotrope titration.

But also, with disease processes such as sepsis,or multi-organ failure, you will get a feel for how far to go up or down.

For example, in sepsis, levo really can be moved up hard to get an effect.

[Ruby Vee, BSN]

don't forget to check with your prescriber . . . which one do they want titrated first? are they using the epi drip for function or for pressure? and there's always a charge nurse -- you can ask her for help and/or advice.

[CCRNDiva, BSN, RN]

Ruby Vee, I was going to say the same thing. For instance if the patient has an ischemic bowel, you may want to wean the Levo first to decrease further ischemia r/t to clamping down or vasoconstriction of the vessels. Some nephrologists want Levo weaned 1st for the same reason. If the patient is bradycardic and hypostensive you would want to wean the Dopamine last in order to preserve the inotropic effect. If the patient has become tachy or experiencing arrythmias, Dopamine should be weaned first as it frequently causes tachy arrythmias.

[Biffbradford]

I would titrate pressors and inotropes one at a time. Then if they don't tolerate it, it's easy to back track. You might wean Dobutamine to 3mcgs, then start on the Vasopressin or such. In the mean time you're adjusting the Insulin drip per the protocol. Of course, then you get the doc who throws you a curve ball and says; "Cut the Dobutamine in half, then in 30 minutes D/c it and pull the swan. I don't care about the index, or PA pressures. Then the pt can transfer this afternoon." To each, his own!