Titrating

There is a learning curve and this gray area with titration you're sensing is where experience and critical thinking skills come in. You'll soon notice how different people respond to different drugs and get a sense for what you should do. In the meantime follow your guidelines, stay safe and ask questions to the experienced nurses.

The guidelines I'm refering to is a piece of paper copied too many times passed on through nurses, it's not something I was given officially. Like for propofol it says go up 5mcg q5m and down 0.01 q30m. That is just bizarre sounding!

Would it be too "out there" to start with a mid-range dose, say 1 to 1.5 mcg/kg/min and titrate to effect? 30 minutes of high blood pressure is tolerated a lot better than 30 minutes of low pressure.

So say the patient is in MAP 40's.

What would you crank them up to?

The short answer is you crank it up to "whatever works." But no, it is not realistic to wait 5 minutes for every dose change while the patient's blood pressure is tanking. You titrate for effect, and once you have a stable BP you make small adjustments as needed. The more you get used to starting and titrating Levo, the more comfortable you will become with it. Sometimes you'll start higher than others, sometimes you'll titrate faster than others.

Agreed. There is some *art* in this science we practice

Yup. ^^^ Protocols are fine when they work...and can be very dangerous when the pt's body hasn't read them.

With vasoactive gtts, and Propofol which can really drop BP, there is no way I would wait 30 minutes to titrate it down if their BP is dangerously low or dangerously high.

Insulin drip protocols too, I've seen call for way too much insulin based on the individual pt's trends. So say the BG is 250, I've seen gtts call for double the rate; well if it was 400 an hour ago, common sense says we probably shouldn't double it.

I use titration protocols as a guideline, but critically think about every action you take.

Yup. ^^^ Protocols are fine when they work...and can be very dangerous when the pt's body hasn't read them.

With vasoactive gtts, and Propofol which can really drop BP, there is no way I would wait 30 minutes to titrate it down if their BP is dangerously low or dangerously high.

Insulin drip protocols too, I've seen call for way too much insulin based on the individual pt's trends. So say the BG is 250, I've seen gtts call for double the rate; well if it was 400 an hour ago, common sense says we probably shouldn't double it.

I use titration protocols as a guideline, but critically think about every action you take.

You make a perfect example of how these hand written protocols are a guideline for a CCRN to be aware of but not expect it to be your substitute for critical thinking. I'm a travel nurse and some of the facilities I've gone to use the "Glucomander" programs on a computer to titrate their insulin drips. That program will bottom your patient out if you're not monitoring it. I would plug in a glucose result of 93 with the patient NPO and having insulin infusing at 3 u/hr and it would tell me to leave it at 3 u/hr! Uh, no. I'm pausing you and reassessing in 60-90 mins.

"Protocols are fine when they work...and can be very dangerous when the pt's body hasn't read them."

LOVE this answer. Thank you so much! Will pass that tidbit onto new nurses too!

"Glucomander?" Is that supposed to be a compound of "glucose" and "commander?" If so, I'm irritated.

While working my first ICU job, we had an insulin protocol written by one of our docs. It was very apparent to us that it should be used as a guideline, not a specific Rx... It was a staight sliding scale, with no considerations of trends, intake, if the pt just had a dose of chromium, nothing. Anyway, one night I floated to the solid organ transplant floor. One of the nurses said, "We use your protocol, but none of us like it. We kind of follow it, but really don't. No offense." I responded, "None taken. We don't really follow it either."

I love how you said they are not a substitute for critical thinking.

We titrate Levo to a max of 30mcg/min, sometimes 50mcg/ min if other pressors are maxed. We don't titrate it based off of weight. If my patient had a MAP in the 40s I would push a resident to insert an a-line, and I would probably switch my automatic BP cuff to q5 until the MAP was in the 60s. I would then switch back to the standard q15. I would personally start my levo at 10 or 15mcg depending on the size of the patient and how they respond to it. I would rather have to titrate my Levo down than up in order to make sure those organs are perfusing! This is from a county hospital perspective, though. We pretty much do whatever we want at the county haha.

We use mcg/min without weight. Order is usually 2-40 mcg/min and titrate to MAP > 65 mmHg. If the MAP was 40, then I would crank it up as the flow rate would be higher and the pressor would reach the pt faster, once my MAP was about 55, I would start backing off by about 5 mcg every minute or so. Actually if my patient was deteriorating that fast, I would bolus the patient with a 1.5cc of Levo from the bag, but that probably isn't best practice but it beats cracking ribs :)

We use mcg/min without weight. Order is usually 2-40 mcg/min and titrate to MAP > 65 mmHg. If the MAP was 40, then I would crank it up as the flow rate would be higher and the pressor would reach the pt faster, once my MAP was about 55, I would start backing off by about 5 mcg every minute or so. Actually if my patient was deteriorating that fast, I would bolus the patient with a 1.5cc of Levo from the bag, but that probably isn't best practice but it beats cracking ribs :)

Pretty sure the last time I saw a nurse "bolus" her patient with levo she brady'd him down to the 30s-40s HR.