50s M homelessness, DM2, R foot diabetic ulcer (source of infection). came to the ED for weakness. labs drawn. sepsis bundle done. cultures, abg, cbc, renal, etc done.

admitted to the ICU for dka, sepsis w end organ dysfunction, crrt initation.

drips are:
insulin
LR/D5LR
levo @ 35mcg (max 80)
vaso 0.04
angio II 20ng/kg/min (max 80)

labs are attached.

at what point do you decide to run angio? when your max on all pressors? or does a specific lab indicate to run it?

ive had patients who will be max on levo, vaso, neo, epi, then will add angio for the last pressors and lil bit push of bicarb and some methylene blue as last resort.

and i had patients who are just on angiotensin II drip by itself.

and i had patients who are on mid levo and on vaso 0.04 and will add angio II.

whats your experience regarding angiotensin II or giapreza? is there a standard that providers follow when to initiate it?

Edit/updates:

lactate now at 10.50 from 3.90
push of methylene blue
max now on Levo
on vaso
Max on Gia
now adding Epi to sustain MAP 65
stopped pulling on CRRT.
thought about neo, but providers said not for now since neo has a lot of volume and tends to run fast and will be a problem in the long run bec we cant pull on CRRT since pressor reqs are going up.

Update:

patient now intubated. just fent for sedation.
still wakes up and follows commands. RASS -1 GCS11T

max on levo vaso epi neo gia
stopped crrt due to inc pressor reqs
UOP avg 50ml/hr
echo showed 70-75% EF
insulin drip @ 24u/hr w glucose not dropping. still at 400s.
continuously replacing K+ and calcium chloride
CVP 17
attaching flotrac to see hemodynamics
lactat 8
agap still 17

Sorry if this is the wrong subreddit to ask. I work in the ED as an RN. I assumed care of a patient at 3pm who was originally a cath alert when they arrived at 11:30am. CC was SOB, n/v, CP, but also general pain. Last dialysis was yesterday morning. The nurse giving me report told me they cancelled the cath alert because the patient’s INR was 7.3, was hyperkalemic (6.3), and anemic 6.9. I asked the ED doctor the plan for this patient, which was dialysis tmrw and transfusion at dialysis, and maybe a cath procedure? I was like do you foresee any needs for this patient at this time and he said no. I wish I would have repeated his ECG. The nurse giving me handoff gave him a bunch of morphine and zofran. His pressure was 140s sys at triage and at handoff his pressure was a little soft above 90s and the patient appeared stable. Patients blood pressure was soft before I was there, patient had a soft bp throughout my entire shift. Providers were aware. Patient had a recent CABG 2 months ago, on dialysis, has AS, TR, multiple stents placed, cardiomegaly, has HFwREF, afib on cumadin, cirrhosis. Pt was aaox3, was mostly chilling in his bed but would sometimes have these episodes of nausea and generalized pain. So I texted the step down doc to put pain meds for him. He was in the ED my entire shift, we were waiting for a step down bed for him for HOURS. step down doc laid eyes on him and put orders in for vitamin K infusion and protonix. I again asked the plan of care for him (this is around 6 or 7pm, and it was still dialysis then transfuse). Then he started to not look good. I called a rapid at 12:30am. I got the code cart and put him on the pads because I just had a bad feeling. He became diaphoretic as helllll, had new R CP and became hypotensive. We start him on levo, 15NRB. Couldn’t get a pulse ox his extremities were cold. ECG showed inferior wall MI. We were waiting for cardiology for 2 and a half hours, it felt like we were in limbo. Because he was simultaneously getting a bed for CCU, but they also wanted to temporize him before going to cath, and they also wanted to give him fresh frozen plasma to correct his INR, and they came up with this decision at like 245ish? Time in between that we are trying to get more access on him and his IV blew with the levo so we had to do K subq around his arm. Was extremely hard to watch. My patient just kept saying I don’t feel good I don’t feel good, and then He coded at 3am, I was on the phone with CCU giving report and he became unresponsive and his eyes rolled behind his head. We were coding him for a little over an hour, tried to temporize him during the code, he kept going into PEA or asystole, then he had one episode of Vtach so we shocked him, but then he’ll brady and he would respond to the pacing, then go back into PEA or asystole. We never got to debrief on what actually happened so I feel really bad and confused as to why this was his outcome. I feel like this person was failed and died a horrible and scary death. I wonder if he had the procedure would he have even survived? What was there for me to do as an RN?