Vasopressor and Inotrope Titration Orders

Specialties MICU

Published

I have a question with how your hospitals order their parameters for vasopressor/inotrope titration. This is because JACHO just went through our unit and cited us for something that, to me does not make sense.

Currently, if we had a septic patient on a titratable medication, such asl Levophed, the order would look something like:

Levophed 4mg/250ml NS. Start at 5mcg/min titrate for MAP >65. Notify MD if dose is greater than 20mcg/min.

JACHO is telling us that unless there are specific titration intervals, ie: the order says Titrate by 2mcg/min Q5min we are overstepping our scope of practice as ICU nurses. Furthermore, If we titrate faster unless the order is changed.

I don't under stand this.

I was under the impression that the ability to titrate medications within a dose range to within parameters was under the ICU nurses scope of practice. Some patients end up being very sensitive to some of these medications and other require higher doses than expected. As we are weaning them off of these medications, their sensitivity often changes. Some of those patients that were crashing and on max multiple pressors/inotropes initially, become sensitive to that last bit of Levo as we wean them off.

If we end up titrating based on patient response within the ordered dose range, we are now, under this JACHO rep's eyes, outside our scope of practice, unless we end up turning our Intensivist into a secretary taking him away from more pressing matters to constantly change the orders on how we are titrate.

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We titrate Levo just like your facility. Our orders are 0-20mcg/min; titrate to MAP > 65. I was under the impression that working in the ICU gives you a little more freedom. I just had a pt last night that was on Levo; got it weaned down and eventually turned off for 4 hours, but then gave a large loading dose of fosphenytoin which then tanked the BP and had to turn the levo back on. I wouldn't of had time to sit there and increase the rate by 2mcg every 5 minutes. Our docs are way too busy to micromanage all of that.

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Having JCAHO in the hospital is like having your parents to your college for a weekend. You clean your place up, make it look nice and if they give you suggestions, you say oh yeah sure I'll do that. But as soon as they're gone, you're going to make the place a mess and not change your ways.

I'd be shocked if they actually did anything about this.

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Specializes in Cardiothoracic ICU.

Same thing at my place; its really a shame because those medications don't just affect 1 parameter so it really worsens patient care.

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Specializes in Surgery, Trauma, Medicine, Neuro ICU.
Having JCAHO in the hospital is like having your parents to your college for a weekend. You clean your place up, make it look nice and if they give you suggestions, you say oh yeah sure I'll do that. But as soon as they're gone, you're going to make the place a mess and not change your ways.

I'd be shocked if they actually did anything about this.

This. This is exactly what we do. We have the order to cover us but really...we do what we want. They're coding? Levo doubles. Triples maybe. Maybe gets maxed out. If it's that bad...we honey badger it.

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Specializes in Critical Care.

The JC doesn't actually require titration orders to be that specific, but that doesn't mean surveyors won't have completely inaccurate views of the requirements which is one reason why the JC is losing business. I have worked at one facility that required JC surveyors to survey in pairs and they both had to agree on any findings, which did help.

The JC standard on medication orders requires that the starting and maximum dose needs to be specified, and the goal needs to be specific, but the rate of titration does not need to be specified. There does need to be facility policies that establish a common understanding of how the order will be interpreted and implemented. The question I would have asked this surveyor, is "then we'll write 'may titrate from max rate to min rate to off and vice versa q 1 second." I would hope at that point the surveyor would realize that what they are saying makes no sense.

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The same thing happened to us when jchao came and surveyed our ICU. What we did is build into our titration gtt of Levophed is 8mg/250ml with maximum of 40mcg/min and to initiate at 5mcg/min and increase by 5mcg/min every 5 minutes with goal of MAP >65 or whatever the intensivist prefers. This keeps you compliant, but we all know it is extremely difficult and almost impractical to continuously have the intensivist change the parameters as the patient sensitivity changes. It's a hairy situation when jchao starts dipping their fingers in everything. When I started in ICU 3 years ago, this was not an issue. But seems lately it has become a focus of jchao with drip titrations.

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This just came up in my unit recently. Its absurd.

I guess next time I start norepi on a crashing patient I will start at 0.5mike and then wait 5 min to increase by another 0.5

ARRRRGGGG stop the madness

Is JCAHO run by nursing theorists?

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Specializes in Critical Care at Level 1 trauma center.

Ha, silly JCAHO! We stopped using them and switched to a different agency. We are a magnet hospital and our titration guidelines are levo 1-47 mcg/min to keep MAP >60. Epi 1-12mcg/min Vasopressin 0.01-0.04 Neo 20-80 and dopamine 1-50 mcg/min.

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Specializes in burn ICU, SICU, ER, Trauma Rapid Response.

As a result of a JC survey (and an over zealous, uninformed surveyor) we had to do something like that. However instead of changing how the orders are written we have a posted policy about titrating drips. Everybody ignores it and I don't even think new hires are oriented to it. The policy has an out that says something like "unless clinical condition indicates a more appropriate titration schedule", or words to that effect.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
This just came up in my unit recently. Its absurd.

I guess next time I start norepi on a crashing patient I will start at 0.5mike and then wait 5 min to increase by another 0.5

ARRRRGGGG stop the madness

Is JCAHO run by nursing theorists?

Essentially yes.
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Specializes in ICU.
...our titration guidelines are levo 1-47 mcg/min to keep MAP >60. Epi 1-12mcg/min Vasopressin 0.01-0.04 Neo 20-80 and dopamine 1-50 mcg/min.

Interesting rates... A bit different than our typical doses. Is neo 20-80 mcg/min? Seems low especially with your high max rates for levo and dopamine.

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