titrating pressors

EMSnut45, BSN, RN, EMT-P · Apr 29, 2010

I always titrate by mcg/min or mcg/kg/min. Some of our drips come in various concentrations depending on how fast we are using them, renal failure, etc., so I want to know exactly what the dose is. mL/hr is not a dose-- it's a rate. We do record both numbers on our flowsheet, though. The dose (mcg/min or mcg/kg/min) goes under drips, and the rate (mL/hr) goes under intake.

ShaunES · Apr 29, 2010

I gotta be honest, that seems like an awfully dangerous situation, given how potent noradrenaline is and how confusing such a rate is.

Over here we dilute 6mg in 100mL, to make a 60mcg/mL dose, so then your mL/hr is also mcg/min.

We also program these into the pumps, so we see 3mL/hr and 3mcg/min.

I dunno, that seems like an awfully strange way of doing it.

detroitdano · Apr 29, 2010

That sounds like a horrific way of titrating pressors. You're not taught to give half pills for blood pressure, you know the dose, not the size.

Dosages change based on what concentration is on hand. Someone may make a bag up during a code and then pharmacy sends you something else with a totally difference concentration. You can see how this would be a bad situation.

turnforthenurse, MSN, NP · Apr 29, 2010

I always titrate by mcg/min or mcg/kg/min. Some of our drips come in various concentrations depending on how fast we are using them, renal failure, etc., so I want to know exactly what the dose is. mL/hr is not a dose-- it's a rate. We do record both numbers on our flowsheet, though. The dose (mcg/min or mcg/kg/min) goes under drips, and the rate (mL/hr) goes under intake.

I understand that, and as I mentioned everytime my nurse had me change the mL/hr setting I always figured out the dose - exactly how many mcg/min the patient was receiving because I know that mL/hr is NOT a dose.

I just wanted to know if it is standard to titrate by mL/hr or by mcg/min. The nurse I was with the other day has worked in the MICU for 30-some years but it just seemed weird to me that she had me change the dose by mL/hr (which I know, is not the dose) instead of telling me to increase or decrease by 5mcg/min.

Cinqly, BSN, RN · Apr 29, 2010

I always titrate in mcg/min or mcg/kg/min. We program our pumps with the concentration (usually 4mg in 250 ml or 8 mg in 250 ml), and set it up so that it can be titrated by mcg. I think this is safer practice because you are sure of how much drug is going in. Some nurses still titrate based on mL, but I find that to be risky since depending on the concentration of the drug the mL can change drastically. Furthermore, it is bad practice to have a policy (official or unofficial) to titrate up or down by "5". Patients can have different sensitivies to a drug, and although when initially starting a drug you may always start levophed at 5 or 10 mcg/min, the titration is usually different for every patient. I've had patients where I wean them by 5 mcg every 15 min, and patients where I had to wean by 0.5 mcg every 2 hours because they were so sensitive to changes.

When in doubt, always go with the safest methods. Good luck!

Rabid Response · Apr 30, 2010

In my ICU we always use mcg/min, mcg/kg/min, etc... and never mL to titrate pressors. However in our CVICU to which I am constantly floated, the nurses titrate by mLs (but not always 5 mLs at a time!) for some reason, although the electronic MAR converts the mL to mcg/min, mcg/kg/min etc... when the mLs are entered. I swear it is a cultural thing, individual to the units. When I am in CV, I still use the actual dose to titrate because I feel more in control that way even if I am just break relief and watching someone else's patients.

Regardless of what hospital unit, our hospital's standard orders for pressors are written for titration by mcg, not mL. For instance, our standard Levophed order is to start at .05 mcg/kg/min and titrate up by 0.05 mcg/kg/min every three minutes to a max of 0.5 mcg/kg/min to maintain a MAP of 65. Most of us in ICU take liberties with the amount by which we titrate (some patients fare better weaning off Levo by .01 mcg/kg/min increments for instance) so none of us is really following the order exactly, but I feel that titrating by mcg is more likely to stand up to an audit or close inspection than titrating by mL.

Titrating by 5 mL increments seems a bit like flying by the seat of one's pants, frankly, and I would not feel safe if that was the usual practice on my unit.

RescueNinja · May 1, 2010

I always titrate by mcg/min or mcg/kg/min. Some of our drips come in various concentrations depending on how fast we are using them, renal failure, etc., so I want to know exactly what the dose is. mL/hr is not a dose-- it's a rate. We do record both numbers on our flowsheet, though. The dose (mcg/min or mcg/kg/min) goes under drips, and the rate (mL/hr) goes under intake.

Ditto! :up:

CNL2B · May 4, 2010

I bet you anything your hospital has a policy on this (probably buried somewhere in the pharmacy.) I don't think that anywhere it is actually kosher to titrate by mL's anymore. I worked at a very backwards, small-town community hospital in rural FL where nurses were still doing this and when I moved back to a metro area I found out this was very frowned upon. Like everyone else says, you should always know the DOSE you are giving your patient. Newer, better IV pumps allow you to titrate by the mcg/min or the mcg/kg/min and automatically figure out the mLs/hour for you -- at my facility this is the case, and our drips are run to the 10th of a mL/hour (e.g. 5.7 ml/hour.)

Also, FYI 20 mcg/min of levophed is alot. I'd have to look but I think it is the top (or near the top) of the dosage range. In a good IV drug book, they usually give you titration tips, like titrate this drug by X number of mcgs/min every X minutes to desired effect. Usually, titrating off you can use those same guidelines (just down instead of up) - usually as a newbie nurse it's good to do your research and see what the experts say. Of course, individual responses vary. I would titrate a pressor off a lot faster if the B/P I was working with was 150/85 as opposed to 115/60. Eventually, you get a feel for how fast and to what degree each of your pressors work and you are better able to use your own judgment and decision making skills.

Chisca, RN · May 5, 2010

It may be that particular nurse titrates drugs in 5 ml increments. If this is the way all the nurses there practice be afraid, be very afraid. :uhoh21:

leesespieces · May 6, 2010

Titrating by mL/hr is NOT a standard of care, and if you ask me, also quite dangerous. I agree with the other posters, you should always titrate by dose, not rate. At my facilty, our concentration is 4mg/250mL and I always titrate by mcg/min; sometimes by 5's, it all depends on how labile the patients BP is, sometimes I'll titrate by 2's etc. Hope this helps!

wakaro · May 7, 2010

Meds titration should be done in dosage not ml/hr. Idealy, we talk in terms of dosage but not mls. I think currently Its required for the docs to give you titration orders on how to titrate your drip. I do agree with all above we should use mcg/min BUT not ml/hr.