Thanks for the input, everyone.

[enhance]

Thanks for the input, everyone.

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[TaoistDoc]

I wouldn't do it either. If norepi is maxed out and your patient is still hypotensive, I would be worried that the patient either doe not have enough volume or not enough contractility. An echocardiogram would be indicated in that case to differentiate the two. Adding on more alpha at that point can make the situation worse IMHO.

Although 4 mcg/min norepi is only .06 mcg/kg/min in this patient so you have room to go up on it so I would do that first, assuming this is early stage sepsis.

 

[Planktonmd]

I wouldn't do it either. If norepi is maxed out and your patient is still hypotensive, I would be worried that the patient either doe not have enough volume or not enough contractility. An echocardiogram would be indicated in that case to differentiate the two. Adding on more alpha at that point can make the situation worse IMHO.

Although 4 mcg/min norepi is only .06 mcg/kg/min in this patient so you have room to go up on it so I would do that first, assuming this is early stage sepsis.

The neo dose here is very high while Norepi is too low, I think the neo is not doing anything anymore due to tachyphylaxis and it can be stopped.
I would stop the neo, increase the nor-epi and maybe add low dose vasopressin.

 

[pulmoblast]

Agree with addition of vaso, check for fluid responsiveness, consider addition of steroids (are there any clues in the history which may point towards adrenal insufficiency?)

 

[Ignatius J]

Makes no sense. Some ICUs can be very scary.

I got a call one time from a radiologist who needed emergent nephrostomy tubes in a patient. The patient was "actively decompensating" and "maxed out on levophed" in the ICU.

"You need to get here ASAP!"

What was the line and intubation status, you ask?

The levophed was going through a PIV, no arterial line, and the patient was on a Venti mask.

 

[deleted547339]

Surviving sepsis campaign suggests Levo->Epi. Vaso is also acceptable as needed. Advises against phenyl unless tachydysrhythmias cause by beta-agonists.

Unless there is more to this story, the patient shouting be on neo.

 

[G-Man82]

Did they try fluids? That's still a mainstay in treatment of sepsis, though early initiation of norepinephrine is ok too after failed fluid challenges. I pretty much never use phenylephrine in the unit and avoid it in sepsis unless I'm on my 4th pressor already. But at that point it's time for a plan of care meeting ... And a priest.

 

[Hoya11]

This neo dose is medium. The levophed dose is medium. Where I trained you ran these two pressors together all the time. WHen neo doses are approaching 250-300 mcg/min ( or a bag that is 40-100mcg/ml is free flowing on a micro drip ) and you cant have your ideal SBP, then levophed, possibly epi. I think running both minimizes have to run too much of either one alone and gives a nice balance, not too tachy, keeps EDV up, and ensures increased cardiac output. These septic guys come in with a HR of 120-130, neo makes it 100-120, add fluid and possibly colloid to the equation and the death spiral starts to reverse. I am pro-neo and get annoyed when I have to switch it over in the unit due to RN/policy maker preference.

 

[PainDrain]

Makes no sense. Some ICUs can be very scary.

I got a call one time from a radiologist who needed emergent nephrostomy tubes in a patient. The patient was "actively decompensating" and "maxed out on levophed" in the ICU.

"You need to get here ASAP!"

What was the line and intubation status, you ask?

The levophed was going through a PIV, no arterial line, and the patient was on a Venti mask.

Do we practice at the same place? I have seen multiple pressors through PIVs all the time with no A-line. The main ICU guy here believes A-lines lead to infections and ischemic limbs or some nonsense.

 

[fakin' the funk]

Levo is 4mcg/min, neo is 50mcg/min. Pt is 60kg, about 6foot or 6foot-1.

As another said, the norepi is 0.07mcg/kg/min (medium) and the phenylephrine is 0.8 mcg/kg/min. Both medium-ish.

The issue isn't that this is dangerous, or only that it's redundant (which it is), it's that you've complicated the issue and made it seem like you're doing more, without actually doing more.

(Practically speaking, a lot of times pts will get started on phenylephrine peripherally first [since it's felt to be safer going peripheral -- not a lot of truth in that] and then get some "real" pressors/inotropes going once reliable and/or central access is established. Not defending this at all, but it's just "the way it's done" in places)

My advice is: simplify to one vasopressor (SSC supports norepi first), then consider adding either vaso or epi or fluid depending on your various parameters, bedside TTE exam, etc.

 

[OB1🤙]

Agree with what fake said. Also approve the Jet-ish bolding. Would like to see font size manipulation in the future.

Norepi with neo is silly. If neo isn't cutting it, stop it and go with levo.

The other tangential but related point I'd like to make- don't run dobutamine and epi together. DBX acts as a partial agonist to the epi. Turn it off and start epi instead if the DBX isn't cutting it.

 

[urge]

If norepi is maxed out

What is your definition of maxed out?

 

[urge]

Septic pt in the ICU at OSH on Levophed and Neosynephrine. We would never do that at my institution. Thoughts?

Levo is 4mcg/min, neo is 50mcg/min. Pt is 60kg, about 6foot or 6foot-1.

Not very elegant but I'm sure it works just fine.

 

[PainDrain]

During my training it went like this. Neo was good for a little boost in the OR but it didn't really have a role in ICU. The algorithm went Levo. +/- vaso, epi, and then dobutamine. We rarely used dopamine. Also it was rare to use dobutamine in straight sepsis.

 

[Femtochemistry]

...why is a "septic" patient on Neosynephrine?

 

[TaoistDoc]

What is your definition of maxed out?

Maxed out typically for me is 0.3 mcg/kg/min. Although I know that it can continue to be effective at higher doses, I would want to rethink the situation as to whether the patient needs more alpha versus volume verdus beta.

 

[Sonny Crocket]

Ive seen dobutamine work in sepsis but am not sure why. Is it just the better cardiac output? Doesn't it decrease PVR? Exactly what we don't want?

 

[fakin' the funk]

Ive seen dobutamine work in sepsis but am not sure why. Is it just the better cardiac output? Doesn't it decrease PVR? Exactly what we don't want?

Usually if you need inotropy (because your patient is circling the drain on NE/vaso) you don't have any BP to work with, which makes dobutamine a poor choice.

My progression is fluid+NE --> NE+vaso --> NE+vaso+epi with more fluid given along the way based on PPV or TTE. Give these additions 60-120 minutes to have an effect and reassess.

Agree that norepi max effect is probably somewhere around 0.2-0.3mcg/kg/min

One place I trained, the default norepi order came with a RN titration dose range "1mcg/min to 80mcg/min," particularly memorable to see the patient with acute MR not doing so well, to find out that hey guess what the patient's on 80mcg/min norepi!

 

[fakin' the funk]

...why is a "septic" patient on Neosynephrine?

Because we (anesthesiologists) think phenylephrine fixes everything!

 

[G-Man82]

Usually if you need inotropy (because your patient is circling the drain on NE/vaso) you don't have any BP to work with, which makes dobutamine a poor choice.

My progression is fluid+NE --> NE+vaso --> NE+vaso+epi with more fluid given along the way based on PPV or TTE. Give these additions 60-120 minutes to have an effect and reassess.

Agree that norepi max effect is probably somewhere around 0.2-0.3mcg/kg/min

One place I trained, the default norepi order came with a RN titration dose range "1mcg/min to 80mcg/min," particularly memorable to see the patient with acute MR not doing so well, to find out that hey guess what the patient's on 80mcg/min norepi!

I kid you not. The MICU where I trained routinely had people on NE doses greater than 100 mcg/min. I even saw one at >200. But that patient was going down the drain anyway. I like norepinephrine a lot, and use it preferentially over phenylephrine if I have it in the OR. But in CCM, I think the norepi maxes out higher, closer to 1 mcg/kg/min before you really don't see any further benefit. My "n" is low ... But then again at those doses how many people actually are slated to survive? I think cardiac patients are a little different unless septic. But even in them, I really like the inotropic effect that norepi has. Norepi + milrinone is one of my favorite combos.

Otherwise, for sepsis, I use the same progression as you in addition to the usual ventilator management.