I've been in ICU for about 2 months now and love it. As I come close to my last phase of orientation (taking my own patients & preceptor has their own too) I'm still wondering about titrating technicalities. No one I've tried asking this at work was sure how to answer, search not very revealing either.
Ok so say you have a patient in septic shock and has levo ordered titrate for MAP >60. I know at my hospital the range is 0.01mcg/kg/min to 3mcg/kg/min. So say the patient is in MAP 40's.
What would you crank them up to?
My titration guide says go up q5min and down q30min. I've for sure seen situations where starting at 0.01 and twiddling thumbs to go up by doubling q5m would be crazy to just let the patient deteriorate as opposed to going in at like 0.06 or something and seeing the response.
Is this making any sense? I guess there is a learning curve with getting comfortable with titrating.
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.
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 :)
I was about to say the same thing as ArmaniX. I did that to my patient a few months back, accidentally. We had a nice run of bradycardia that dipped down as low as 34 for about three minutes before it resolved. We don't typically make manifolds with stopcocks in my unit, but I think I might just start after that experience if I have other things running through the same lumen as my pressors.
i was taught to "go big or go home." if my pt's map is truely 40, i would go 20-25 watch the 5cc goes in the pump then back off to 15-20 then quickly titrate down to something reasonable. last thing i want is stroke but so is aki needing dialysis just because protocol says so. go by your clincal assessment of pt state - protocol s not written to cover all pt. i rememberer running eip at incredibly high rate during code b/c thats only drg pt responded.
Welcome to the dark side... You have received very good feedback. My golden rule that I tell all new staff is to ask questions without guilt. The more you will deal with titration, the better you will get at it. It takes time. Good luck.
I've gotten a much better feel for levo over the past few weeks. Now if I could just get some other vasoactive gtts and get acquainted with them better.
Seems like sepsis has been the flavor recently. Lots of levo.
Protocols are great when you are a newbie and need guidelines! As you learn to titrate, you get a feel for it depending on the patient.
What I teach my newbies is: if the pt's BP is crashing, start at an amount that will give them enough med to start taking effect, then crank it up fast (try doubling) & back off slowly when you wean. If the pt is slight hypotensive, start lower and titrate by less. Aim for less hypotension time overall. No pt is the book or guideline so always titrate to effect. Ask for an Arterial line if needed.
ArmaniX, MSN, APRN
339 Posts
Pretty sure the last time I saw a nurse "bolus" her patient with levo she brady'd him down to the 30s-40s HR.