Weaning off one drip and starting another

ThatBigGuy · Mar 9, 2015

First, every pt is different, and will react differently to each pressor, so titrate slowly. I prefer to not titrate for ~2 hours when I come on, just to get an idea on how the pt is doing on the current rates. Of course, this is as long as the pt doesn't have a MAP of 40 or SBP of 200, or something equally out of range.

You should have guidelines that give a framework on how often to titrate, provided by your facility. If not, ask your charge nurse. Our facility likes to titrate one rate change per hour. I prefer to do my first couple rate changes every 2 hours, again to see how the pt reacts.

If my pt reacts appropriately and steadily, I'll titrate per hour, prn. So first check your facility guidelines, then check with your charge. Then err on the side of caution.

As far as your second pt is concerned, dopamine increases pressure, but also increases heart rate. I have no idea what the rest of the clinical picture is, but I'd probably be titrating the levophed up and the dopamine down, unless the cardiologist had other plans, and considering all the other factors involved.

You'll find that each MD has differing ideas on which pressors to use at a given time as well. Two MDs I work often with both like to start with Levophed, but differ when adding a second pressor: one prefers vasopressin, one prefers phenylephrine.

Needless to say, there are tons of factors involved, between your pt, yourself, the ordering MD, and your facility's guidelines. Your first resource should always be your charge. Get them involved, because they'll have familiarity with the MDs, the facility guidelines, and the pt. They are your first source.

CMSrn2009, ASN, BSN, MSN · Mar 13, 2015

Thanks for the tip. I guess next time I should ask for help- but it seems as though I'm a little too aggressive with turning the first drops off! Should have just gone slower..

dah doh, BSN, RN · Mar 14, 2015

Our facility has a chart for titrations. Unfortunately, patients don't read the chart! I titrate based on patient response as patients will respond differently. I tend not to titrate aggressively in the first or last hour of my shift as I can't always monitor as closely during initial assessments or last rounds...unless the patient is crashing or has very abnormal vital signs that is.

calivianya, BSN, RN · Mar 16, 2015

You are not necessarily unskilled; you just had dopamine on board in both cases. Dopamine is more likely to cause arrhythmias than some of the other pressors. I am not a fan. I always wince when the physician orders dopamine as the first pressor to be give because I feel like it's just a coin toss as to whether the dopamine is going to make the patient better or worse. For every patient it stabilizes, I have at least one that goes from a HR of 90 and a BP of 80/40 to a HR of 130 and a BP of 70/30. Then again, I don't work cardiac ICU so usually my patients don't need the cardiac effects of dopamine and would do much better on something that hits SVR more strongly than the heart. The only time I like dopamine is if the patient had a problem with bradycardia to begin with.

The way I like to titrate when dopamine is on board is if the patient's HR was originally normal, once the HR starts creeping over 100 I stop titrating the dopamine and titrate something else because the HR's only going to go up from there.