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msharpe1047
08-12-2003, 01:43 PM
I had a pt this morning that was 71 yo, hx: Asthma, HTN, diabetes, heart problens and was a dialysis pt. PTs C/C was SOB and minor chest pain. My question is with someone that is already a dialysis patient, would you give IV Lasix to someone that already has renal failure? TX of pt was 2.5 mg Albuterol HHN and 3 lpm o2 via NC since we were less than 5 minutes from the hospital. Pt stated doing much better after the treatment. I was just wondering if lasix will work on someone that is experiencing renal failure already? Thanks for the replies ahead of time.
:D

IAMedic
08-12-2003, 08:29 PM
I would say "No". Using Lasix can only cause bigger problems by taking the built up water and diverting to already overmaxed system. I don't know for sure, but I could see PE being caused by it. I will ask my medical director and get back to ya!!

eyeOthestorm
08-12-2003, 11:27 PM
In our e.r. our docs use it if the pt.s kidneys still work just a little... and the chopper is on the way to take them straight to emergency dialysis. They will also use a little morphine. If however the pt is having chest pain and an AMI cannot be ruled out then all diuretics are on hold till we get the results of the tests.
Great Question! I can't wait to see other answers!

ABMedic
08-13-2003, 03:48 AM
An old intensivist (now deceased) once said to me - To pee is to be, if you don't pee you won't be!"

In the case of CRF - chronic renal failure the question to ask the patient is - do you still make urine - albeit the quality and quantity of urine may not be good, it is still possible to have some diuresis with diuretics - however - the doses of lasix required can be extremely large - I have seen 240 mg ordered - diluted in an infusion - since high dose lasix is ototoxic.

Does it have a role in prehospital management - probably not - just my opinion, the focus in this setting is to transport to a facility where dialysis can occur.

Episodes of acute renal failure are a different fish, and the management includes treating the underlying cause - be it prerenal, renal or postrenal causes. Interesting in CRF is the need to have a high index of suspicion regarding hyperkalemia in these patients. It is one case where you treat the monitor and not the patient.

ABMedic

twocuts
08-13-2003, 09:57 AM
Renal failure or no renal failure - the most important treatment for pulmonary edema in a high pressure system is not Lasix. Nitro and PPV are going to produce the fastest results.(in my opinion). Therefor, I use what some of you have mentioned to make my decision.

No urine production = No lasix
Some urine production = Lasix

Flash pulmonary edema is a big problem with these dialysis patients. What they really need is emergency dialysis. What I do for them is usually geared toward decreasing afterload and pushing the fluid out instead of relying on Lasix, which works later anyway.

Corey

msharpe1047
08-13-2003, 10:41 AM
Thanks for the Information. This was a question I had and there has been some great advice. It is good to know that there is a place where we can get answers to questions. Thanks again.:p

ABMedic
08-13-2003, 12:28 PM
I hate late nights - laughing - because I missed the point of the post - I agree with twocuts - the treatment goals in pulmonary edema should be directed at reducing preload and afterload - then managing the fluid overload - my post was restricted to the issue of renal failure and the utility of diuretics - which is an interesting topic that is not discussed often.


ABMedic

RoryEl
08-15-2003, 04:58 PM
What were their breath sounds? Wheezes, wet? What was the ECG? P waves, T waves and QT? When was their last dialysis?

Weruj1
08-15-2003, 06:41 PM
I am with the belief that you can give Lasix (if they need it) for CRF but I also beleive it takes a pretty good dose. I would not just give it in this case unless the patient clinically matched the protocol.

msharpe1047
08-16-2003, 09:45 AM
Pts breath sound where wheezes and I am not able to put the monitor on pts yet till I go through oral boards with the local OMD. I thank eveyone for their responses.

BCALS11
08-16-2003, 06:33 PM
If they are actually in CHF precipitated acute cardiogenic pulmonary edema, preload reduction, followed by controlled (chronic) after-load reduction in the hospital setting, seems to be the name of the game. Nitrates, furosemide, and morphine all work in concert to reduce pre-load in failure patients. The reduction of after-load requires significant quantities of NTG (< 10mg in a relatively short period of time which equates to 25 0.4 mg sprays or agressive IV administration) and time so really, pre-hospital efforts are aimed at pre-load reduction coupled with improved oxygenation and ventilation.

Furosemide - By a direct venodilation effect, furosemide temporarily increases glomerular filtration rates, increases the venous capacitance, and decreases peripheral vascular resistance. The net result after administration is decreased ventricular preload and the relief of pulmonary congestion seen in CHF and acute cardiogenic pulmonary edema. Furosemide also works to increase pulmonary function by acting locally to decrease bronchial reactivity (the mechanism is unclear in the literature). These beneficial effects are seen almost immediately after administration and peak somewhere around 5-15 minutes. After 30 minutes or more you start to see the effects of diuresis due to the Loop effects of the drug. As others have mentioned most correctly, the patient needs to be making at least SOME of their own urine for you to even consider giving furosemide in the type of patient being discussed in this thread - complete renal failure is a contraindication to the administration of furosemide.

Morphine - Histamine mediated vasodilation coupled with decreased catecholamine response and anxiety (and thus a decreased respiratory rate due to a decrease in tone of the thoracic pump) work together to reduce venous return to the right heart and preload. Add in the significant analgesic effects of MS, and you have the narcotic of choice in the treatment of acute cardiogenic pulmonary edema secondary to CHF.

Nitroglycerin - NTG primarily dilates the peripheral veins but to a lesser extent it also dilates peripheral and coronary arteries. As a result, there is a significant reduction of venous return to the heart (preload), a slight decrease in peripheral arterial resistance (after-load), and a decrease in MVO2 demands. Larger doses or IV administration MAY produce more significant after-load reduction.

IPPV With BVM - Yup, it's a good thing. Few of these patients require intubation if IPPV and pharmacological interventions are handled appropriately and delivered in a timely manner.

Inhaled Beta-2 Agonists- Maybe.... guess it depends on if you have refractory bronchospasm after dealing with the interstitial bronchial fluid shifts through other typical therapies. Side effects on heart rate and potassium levels should be a consideration for the continuing course of your patient's therapy.

Dimenhydrinate - Why not? A little prophylactic effort at dealing with potential nausea after the administration of MS coupled with the significant anxiolytic effects (decreased thoracic pump action = decreased venous return to the right heart) seen with this drug certainly wouldn't do any harm.

Anyways, those are my ramblings for the day...... hope that there was something useful in it. Be safe.

ABMedic
08-17-2003, 12:09 AM
Inhaled Beta 2 agonists - use them all the time both prehospital and critical care for acute pulmonary edema - and really is there a good reason not too? I don't believe that there exists any rationale to not use them - inducing tachycardia - generally unfounded in almost all patients - not to say that we don't RARELY observe a patient that is ultra sensitive - but again extremely rare!

Potassium levels are only affected after substantial continous sidestream administration - hence it's utilization in hyperkalemia although the amount of potassium shifted intracellularly is still minor compared to other pharmacological strategies.

ABMedic

IAMedic
08-18-2003, 11:39 AM
After talking it over with my medical director, he says that it is okay to go ahead and push it, if you think they need it. Chances are they have bigger problems already. Besides, he said if your protocols call for you to push lasix, you would be breaking protocol not doing it.

Plus, he said "The ICU/CCU doctors/nurses need some patients that make them think, every once in a while".

twocuts
08-19-2003, 08:29 AM
Well, there exists a good explanation of how to treat a CHF patient. IF THEIR KIDNEYS WORK. I believe the discussion started as a renal failure situation. I don't dispute what is written, someone can read. I can give that patient lasix until I am blue in the face, but, until I get that patient to dialysis, the root of my problem still exists.

hageremtp
08-19-2003, 05:27 PM
Besides, he said if your protocols call for you to push lasix, you would be breaking protocol not doing it.

Protocols are ment to be broke....oops wrong saying. Protocols are just guidelines, not something to live or die by. Our old director was back here last week visiting. He was talking to our new director, who was really talking up our 'new' protocols. He said that everyone of us passed our protocol exam with flying colors. The old director looked at the new director and told him, " Protocols are for the stupid people anyways. You have good medics on staff, and I dont see then really needing the protocols anyways. But if you want to brag go ahead and lay it one me." That was the end of that story! :D

ABMedic
08-19-2003, 07:53 PM
I agree with Hager - we changed the title of our "Medical Protocols" about 10 years ago to "Medical Control Guidelines" because everyone recognized that they were just guidelines and deviations must occur in the medical interest of the patient. It's been emphasized that you could follow a protocol flawlessly - and still be wrong for the individual patient. Certainly guidelines are better and emphasize that paramedics are not "Red Box then Blue Box" clinicians.

ABMedic

Weruj1
08-19-2003, 08:08 PM
I am amazed how well we all discuss things ! we have very agresssive protocols and yet out Medical Director gives us both great standing orders and the abiltility to really treat the patient vs the ol cookbook protocol !!!!! I love these forums !

twocuts
08-19-2003, 09:26 PM
I am glad to see this topic come up, even though that is not how this thread started. I agree, protocols are kind of a thing of the past. When I have new cadets come in it is hard to get this concept across. Depending on where they are from, it is kind of a new thing to grasp. Especially medics from Southern California. They still have to call for D50!!

I explain it like this: As long as you are familiar with two things you are on your way to being a good clinician.

1. Pathophysiology. Know how the body works, what triggers what and how do things compensate and interact.

2. Pharmacology. Know what your drugs do. Very well.

If you evaluate your patient, and you use sound judgment based on pathophysiology and pharmacology, you should be within a protocol.

Here is my take on a "protocol". YOu have a standard that says you give diltiazem to a-fib/ a-flutter. You run into someone having palpitations with a rythem that is fast and irregularly irregular. You would deduce that this would be a-fib. It probably is, however, the rythem is a bit wide. You say, well, the protocol says give diltiazem. Ok, you give it and the rythem shoots out of control Congratulations, you just treated an accessory pathway set in a-fib. Most likely WPW. You just followed protocol and blocked the calcium channels and left the sodium channels to do their thing unnopposed.

hageremtp
08-19-2003, 09:59 PM
Especially medics from Southern California. They still have to call for D50!!

Ah, First company I worked for was this way. Boy was that a pain in the rear end. Aside from that, after you called in if you didnt do it you had to write up a deviation of protocol report. So lets say, just for example, you call for a NEB after hearing wheezes. You get the pt on the cot and moved out to the truck, where you reassess the pt. You no longer hear the wheezes, but since you called for the NEB in the house and didnt give it, you were in violation of protocols. I got into so much trouble there. I had stacks of deviation reports. WHY? I would call in to get the things I might need. The Doctors knew this, knew me, and trusted me. But to get around the calling issue I had to do it. Trust me the manager there would play back radio traffic from the night to hear what kinds of calls we went on and what was done. The whole darn place was anal, further more backwards anal, thus the reason I left.

Now I work in a smaller place. I work alot closer with all of the Docs and Nurses. They know what we should have done, what they expect us to have done, and what our guidelines state. However, if we deviate away from them they understand. Point here.....I forgot it! I am just going to stop now............

msharpe1047
08-20-2003, 07:38 AM
I agree that protocols are meant more as guidelines. Our protocols are in place but we don't have to follow them to a T. Because it states something doesn't mean that we have to give certain meds. The doctors and nurses around here know most of the provider and will support them. If the treatment doesn't fit the assessment, I will treat my patient's s/s. The good thing is if we have questions the docs in the ER are pretty good about answering them and providing the reasoning behind certain orders that they give us. Well I start the paramedic class on tuesday and I will have to work saturdays at my regular job to make up for the lost times on tuesday so the next 10 months will be very stressful and I know I will have questions for y'all. I am thankful for these forms because You can get a wide variety of information on just about any topic and everyone puts in their $.02 worth. Thanks again for all the info.
May god bless us all.

jaybird210
08-21-2003, 07:49 AM
I've got a little protocol joke fer ya (Hi Josh! Don't see me here, much, do ya?):

I'm sure all of you have some kind of a "Closest-appropriate-hospital" requirement for transport in your systems. We do, also. The closest hospital to us is about 12 minutes out; four-bed ED, not much for capability (although that dude in the lab coat is STILL a doctor, and I'm not). Anyway, our resoucre hospital is about 20 minutes away; and our most-frequently requested hospital is too. Now, this most-asked for hospital also has a cath-lab, in fact, our resource hospital frequently flies their MI patients here for cath.

So, we have gotten our boobies in a wringer because we would typically transport to the hospital of choice (or the APPROPRIATE hospital) w/o calling for the okay for a bypass of closest hospital. So we have gotten very good about calling for this, lately.

Couple days ago, we had a pt asking to be transported to our resouce hospital. No problem. I called for a "bypass." The nurse couldn't understand why I was calling for the okay to bypass to come to them! Uh, you aren't our closest hospital.....:rolleyes:

We'll see how long this lasts....

hageremtp
08-21-2003, 01:57 PM
With only one Hospital in my area there is not an issue like you have. We transport all pt's there, and then they can be sent out if need be!

ALSfirefighter
08-21-2003, 03:20 PM
This is one of those topics that usually gets floated around in every new pharmacology class that I've assisted with, as well as my own class when I became a medic. It has also come up several times in several different call audits/cme's at various facilities hosting them. Many of my instructors and medical director(s) (to include those whom have conducted the audits/cme's) have never shied away from the "go ahead and give it" regardless of kidney function. Even if you give 100mg, that's only 10CC's of additional fluid your adding to the patients vascular system, and even if it works a bit, its better then nothing, and if it doesn't work at all...so be it. Our standing protocols call for O2, EKG, IV, then SL NTG every 5 mins. systolic dependant, and then 40-80mg Lasix IVP, then 1/2-2" of Paste. No where can I find in either the Mosby's Paramedic Textbook, Revised 2nd addition, 2001 or the latest edition of Mosby's Nursing Drug guide, where it says that Lasix is contraindicated in patients suffering from renal failure. Then our medical control options on top are still the classic, additional lasix up to 140mg, MS, NTG SL and Paste, etc. But...and note I said but...while I still follow my standing orders based on my diagnosis, if they do tell me they have complete renal failure, I still treat on the basis that my overall goal is to get the patient to the ED to recieve dialysis and other treatments options that are not available to me.
As far as the lung sounds...you have to love those patients who present with "cardiac asthma." This is a presentation that I wish every medic student I have with me could experience while on field rotations. While I have never been a cookbook medic and we are somewhat flexible in our protocols, I have never taught or advocated any student or another paramedic in giving of bronchodilators/beta 2 agonist for pulmonary edema, or the presumption that all that wheezes is asthma. We are still held accountable to our protocols under QA/QI and for us, bronchodilators (we use combivent/straight albuterol) is for working diagnosis of ashtma only. I have seen many a medic keep slapping nebs on a patients face who really needed the Acute Pulmonary Edema protocol to handle the symptomology.

Anyone want to start a new post on the "wheezing" issue?
___________________________
IACOJ Bureau of EMS Chairman

ABMedic
08-21-2003, 11:01 PM
ALSfirefighter - I respectively disagree with your stand on bronchodilators usage in pulmonary edema. Ventolin (albuterol) can be used safely and with clinical efficacy in both the critical care (CCU/ER) and prehospital setting in the management of pulmonary edema concurrently with other pharmacological agents. Although the usage of Atrovent or Combivent (a combination of Ventolin & Atrovent) has not been supported clinically or in theory to my knowledge.

One must appreciate the pathophysiology of the wheeze with respect to the underlying disease. It is a topic worthy of debate, perhaps we should start a new thread.

ABMedic

hageremtp
08-22-2003, 05:54 PM
How about if I just bump the debate from about a year ago?

ALSfirefighter
08-23-2003, 06:27 PM
ABMedic,

I'm not completely understanding what there is to disagree. I never made a stand on the clinical aspects of the use or non-use of bronchodilators in regards to Pulmonary Edema. I said I do not use them or teach the use of them to students, on the basis that their use under our protocols, is for the working diagnosis of Asthma. I have read all the literature and have seen other protocols that use them for Pul. Edema, and many of our discussions on here. The topic of what protocols are meant as stone or guidelines is completely agreeable and is dependant on where you operate as we all know. We have had many medics who've had "discussion" after being QA'd on giving bronchodilators to pulmonary edema, when Acute pulmonary edema was the working problem. If they turned around tomorrow and put in our standing orders for pulmonary edema that bronchodilators are administered.....I'd give it. Until then, my protocols, are my protocols and am not gonna risk my credentials on a protocol violation, nor will I take responsiblity for telling someone to violate them.
So, are we at somewhat of more understandble agreement of what I said?
___________________________________
IACOJ Bureau of EMS Chairman

ABMedic
08-24-2003, 12:02 AM
ALSfirefighter - these late nights are taking a toll on me - laughing - I obviously misread what you had written regarding beta agonist usage - certainly I agree with you that we all must practice within the clinical guidelines we are given.

ABMedic

ALSfirefighter
08-25-2003, 06:56 PM
LOL, I know all to well brother...all to well.

When I read your post, I knew somethign was amiss, many of us know each other all too well in our literary style and capabilities.