How to titrate drips: a provider's perspective

Titrating drips in the critical care environment can be one of the most exciting things a nurse can do, but also one of the scariest. Drip titration requires critical thinking, autonomy, confidence, and a deep knowledge of the medications.

What is drip titration?

Titratable drips are medications that are ordered by an LIP, and the dosing is determined by the nurse, based on a set of parameters. Titratable drips can vary from vasopressors, paralytics, sedatives, inotropes, insulin, pain medications, and anti-arrhythmics.

Vasopressors

When a provider orders a vasopressor, you need to move fast. These drugs are not 'scheduled' medications in that the patient usually needs them before they are even ordered. Often, you will take verbal orders for these medications, so it is very important that you learn the typical doses. Vasopressors require monitoring equipment, blood pressure, and cardiac monitoring at a minimum. These drugs can have tremendous side effects, including cardiac arrest. When titrating these drugs, not only is there an objective way to do it using the order you were given, but there is an art as well. For example, if you are about to bolus your patient with a sedative, titrating DOWN on a vasopressor beforehand is probably a bad idea, as one would expect blood pressure to drop with said bolus. You need to apply this logic to all nursing care you provide. Do not be intimidated by vasopressors, as they are a key tool in critical care, but do respect them.

Paralytics

These drugs are used to paralyze a patient, generally someone who is in severe ARDS. The patient must have a definitive airway to receive these drugs. When titrating them, you will use a combination of ventilator synchrony, deep tendon reflexes, and a tool called the train of four. Information about the train of four is available in a separate post. The essential things to remember when titrating paralytics are that the patient must have a definitive airway, and they MUST be heavily sedated. It is a sentinel event to paralyze a patient without sedation. Some of these drugs have reversal agents, depending on their mechanism of action.

Sedatives

Most people have heard of propofol from pop culture, but there are numerous other sedatives that you should get to know as a critical care nurse. Some of the sedatives are incredibly powerful, some have severe adverse effects, and some provide what we call twilight sedation, which is more of a slight 'buzz' that allows the patient to be more compliant with care.

When titrating propofol, expect a precipitous drop in blood pressure. If the provider is ordering propofol, it is advisable to ask them which vasopressor they want to hang as well. Very few patients will have the ability to maintain their own blood pressure on propofol.

The benzos, traditionally known as Ativan and Versed, are effective means of sedating, but cause large drops in blood pressure as well. They also tend to 'lag' around, particularly Ativan, and it can be hard to wake your patient up quickly after stopping these meds.

Dexmedetomidine, in the simplest terms, is similar to the IV version of clonidine. It can be given to people who do not have an airway, as it very minimally affects respiratory drive. Be careful though, as it can cause bradycardia and low blood pressure. Dexmedetomidine can also cause fevers with prolonged use, so be on the lookout for febrile episodes in your patients.

Ketamine is another agent you will see in the critical care environment. At small doses, it will not affect the patient's respiratory drive. The drug's effects are very dose-dependent, meaning dosing is particular to the condition you are treating. Ketamine is also helpful in patients who have severe asthma as it causes some bronchodilation.

There are other sedative agents, but the ones listed above are the most common ones you will see.

Inotropes

Inotropes can be titrated, but are usually fixed doses that are changed based on several factors, normally a mixed venous oxygen saturation, or cardiac output/index. You can draw a mixed venous from the distal port of a central line. The best sample is from a Swan-Ganz catheter, but these are quite rare. Some of the inotropes can actually cause some degree of hypotension, so their use is limited. The most common inotropes you will see are dobutamine, which is very quick-acting, and milrinone, which works slower but has multiple uses. Some patients are even discharged home on these medications.

Insulin

Regular insulin can be given as an IV infusion. It is usually titrated based on blood sugar or the anion gap. The most important thing to do with an insulin drip is to check the sugar often, a minimum of one time per hour. Insulin will also cause hypokalemia, so advocate for frequent labs. Outcomes are proven to be better in patients who have tight glycemic control in the ICU, so many of your patients will receive this drip, even without a diagnosis of diabetes.

Pain

Being intubated is extremely painful, and the proper thing to do with an intubated patient is to control their pain more than blasting them with sedation. Many patients do not remember being intubated, but they do remember the pain they were in. Advocate strongly for pain drips in a patient with a breathing tube. Find a dose that works for them. Your chronic opiate users are going to require very large doses. Just remember to discontinue the drip when you extubate your patient.

Antiarrhythmics

These are your cardiac drugs, your digoxin, amiodarone, lidocaine, and diltiazem. There are others, but those are the big four. Follow the orders closely. These medications have drastically narrow dose ranges and require advanced knowledge of cardiac monitoring to safely give them. Do not abruptly shut them off without consulting a provider first.

Other

You can and will certainly hang many other types of drugs, but the generic classes above should be known like the back of your hand. These drugs can save a patient, and they often do, but when improperly used, your patient can die quickly.