Vasoactive Drip Titration

The goal of vasoactive medication titration is to maintain hemodynamic stability and adequate perfusion while using the minimal amount of drug necessary.

There is no one effective way to titrate vasoactive medications. It is based on clinical endpoints such as maintaining mean arterial pressure (MAP) > 60 mm Hg, urine output to > 0.5 mL/kg/h, or a cardiac index > 2.5 L/min/m2

Titration of these medications should be based on clinical response.

In general, titration should not be any faster than every 5-15 minutes, because of the short half-life, the potential for drug accumulation causing an overshoot of the therapeutic goals resulting in hypertension, arrhythmias, or hypotension when down titrating.

When a patient is on multiple vasoactive medications, for example, norepinephrine and vasopressin guidance should be obtained from the provider on which drug to titrate first. Always refer to your physician's orders for guidance.

According to TJC (The Joint Commission) recommendations, an order for a titrated medication requires 7 elements:

  1. Medication name

  2. Route of administration

  3. Initial or starting rate of infusion (dose per minute)

  4. Incremental units at which the rate of infusion can be increased or decreased

  5. Frequency of incremental doses (ie, how often the dose [or rate] can be increased or decreased)

  6. Maximum rate (dose) of infusion

  7. Objective clinical endpoint (eg, Richmond Agitation-Sedation Scale score, blood pressure, pain score)

    For example, a titrated medication order would say:

    Start [medication name] drip at 10 mcg/kg/min.

    Titrate by 5 mcg/kg/min every 5 minutes until desired patient response and/or numeric target (e.g. RASS =3) is achieved.

    Maximum rate of 60 mcg/kg/min.

Vasopressors can cause life-threatening hypotension and hypertension, dysrhythmias, and myocardial ischemia.

Reduce infusion rate gradually; avoid sudden discontinuation.

Below are the usual initial doses for vasoactive medications and the usual concentrations. (sometimes drips have to be concentrated to minimize the volume the patient is getting).

Any change in concentration should have a physician’s/provider’s order.

Norepinephrine Initial Dose = 2-5 mcg/min Usual Concentration = 4 mg/250 mL D5W

Epinephrine Initial Dose = 1 mcg/min Usual Concentration = 1 mg/250 mL D5W

Phenylephrine Initial Dose = 20-80 mcg/min Usual Concentration = 10 mg/250 mL D5W or NS

Vasopressin Initial Dose = 0.03 units/min Usual Concentration = 50 units/50 mL D5W or NS

Dobutamine Initial Dose = 0.5 - 1 mcg/kg/min Usual Concentration = 250mg/500 mL D5W or NS

Dopamine Initial Dose = 2.- 5 mcg/kg/min Usual Concentration = 400mg/250 mL D5W

Milrinone Initial Dose = 0.125 - 0.75 mcg/kg/min Usual Concentration = 40mg/200 mL D5W

CVICU Notes:

  • Vasopressors can cause severe local tissue ischemia; central line administration is preferred. When a patient does not have a central venous catheter, vasopressors can be temporarily administered in a low concentration through an appropriately positioned peripheral venous catheter (ie, in a large vein) until a central venous catheter is inserted.

  • Closely monitor catheter site throughout infusion to avoid extravasation injury. In event of extravasation, prompt local infiltration of an antidote (eg, phentolamine) may be useful for limiting tissue ischemia. Stop infusion and refer to the extravasation management protocol for your hospital.

  • Vasopressor infusions are high-risk medications requiring caution to prevent a medication error and patient harm. To reduce the risk of making a medication error follow your hospital’s policy and procedures. Usually, high-risk medications have to be double-checked and co-signed upon initiation and with changes to the rate.

  • Always communicate with the physician/provider when rapid titration is occurring. For example, if you have titrated norepinephrine from 5 mcg/min to 10 mcg/min in under 15 minutes this should be communicated promptly.

  • Do not be shy about asking questions until you understand concepts/rationales!

Hope this information was of value to you!

Feel free to email me at info@cherylpalmer.com for questions.

Resources for this information are on UpToDate.com

Cheryl