# Lasix Drip. Ever Have One?



## 18G (Mar 20, 2013)

Had a patient today on a Lasix drip. It was the first time I had ever encountered or heard of a patient being on a Lasix drip. Dose was 10mg/hr and was mixed 1:1.

Patient was admitted with CHF/Cardiogenic shock which resulted in renal failure. Pt. had anasarca, needed dialysis, etc. Pt. also had a UTI which resulted in sepsis. 

Dobutamine was also infusing to stimulate renal output. 

Any tips or special monitoring parameters for transport other then the standard for a Lasix drip? Obviously, I reviewed the most current labs, ECG, etc, etc.


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## MagicTyler (Mar 20, 2013)

Had my first last night weirdly enough. Patient with a superior sinus thrombosis. I only monitored it for a 10 min transport though. Pt was A&O X4 and ambulatory, only complaint was a HA.


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## KellyBracket (Mar 20, 2013)

A constant infusion of furosemide is more effective, and actually less associated with side effects than bolus dosing. Generally this matters more when you are giving large doses, or there is impaired GFR.

Edit: Was the dopamine dose really meant to boost renal function, or was it just low-dose dopamine? "Renal dose" is passe in these parts.


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## VFlutter (Mar 20, 2013)

18G said:


> Had a patient today on a Lasix drip. It was the first time I had ever encountered or heard of a patient being on a Lasix drip. Dose was 10mg/hr and was mixed 1:1.
> 
> Patient was admitted with CHF/Cardiogenic shock which resulted in renal failure. Pt. had anasarca, needed dialysis, etc. Pt. also had a UTI which resulted in sepsis.
> 
> ...



I have patients on Lasix drips pretty much every shift. Lasix/dobuatmine is a pretty standard combination for fluid overloaded CHF patients. 10-20mg/hr is a common dosage for acute care patients after an initial bolus of 40-80mg but I have seen drips as high as 40mg/hr. I know in the ICU they can get pretty high. 

I would just keep a close eye blood pressure, urine output (they should have a foley), and EKG. They should be getting potassium replacement but monitor for signs of hypokalcemia especially if they start dumping fluid. For labs I would look at BNP, Bun/Cr, and K. 

Lasix drips are pretty straight forward and usually do not cause acute changes after their initial bolus or dose adjustments. I wouldn't be too concerned transporting a patient who has been on it for a while but would definitely pay close attention if the hospital bolused them and initiated the drip right before transferring the patient out.




KellyBracket said:


> "Renal dose" is passe in these parts.



Same here


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## mycrofft (Mar 21, 2013)

Isn't the effect of Lasix more than a drip? More like a steady stream?
:rofl:


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## jwk (Mar 21, 2013)

18G said:


> Had a patient today on a Lasix drip. It was the first time I had ever encountered or heard of a patient being on a Lasix drip. Dose was 10mg/hr and was mixed 1:1.



What do you mean when you say it was mixed 1:1?


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## VFlutter (Mar 21, 2013)

jwk said:


> What do you mean when you say it was mixed 1:1?



I am assuming 250mg in 250ml


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## Summit (Mar 21, 2013)

mycrofft said:


> Isn't the effect of Lasix more than a drip? More like a steady stream?
> :rofl:



Indeed... or Niagra falls...

I've had a patients on up to 40mg/hr furosemide gtt and it was appropriate. I've also had a where we bolused 40mg, watched them suddenly dump over liter in a very short time, dump pressures, go into afib, lots of ventricular ectopy, electrolyte imbalances... replace electrolytes, and maybe even try to add intravascular volume. Some patients need to be diuresed aggressively... but overshooting is bad.

I like drips over bolusing if it is appropriate. Drips have risks too, but usually it is provider error instead of uncontrollable patient rxn.


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## jwk (Mar 21, 2013)

Chase said:


> I am assuming 250mg in 250ml



That's not mixing 1:1.  Mixing something 1:1 is mixing something in an equal volume of something else.

250mg in 250ml is 1mg/ml.  It is not 1:1 in any standard notation of drug volumes or concentrations.  An order would usually call for just Lasix 10mg/hr and it would be up to whoever mixes it to do it right, which is why most things are now pre-mixed from the manufacturer or by the hospital pharmacy.  Even in the OR, we're supposed to get all our drips pre-made from the pharmacy - not that that always happens.


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## Carlos Danger (Mar 21, 2013)

KellyBracket said:


> A constant infusion of furosemide is more effective, and actually less associated with side effects than bolus dosing. Generally this matters more when you are giving large doses, or there is impaired GFR.



The pulmonologist who ran the SICU that I worked in for a couple years used to say something along the lines of: 

"A lasix infusion vs. a 40 mg bolus every 8 hours is like the tortoise vs. the hare.....at the end of the day you'll get more UO with less drug from the infusion than from the boluses."

We used to run infusions at 2-4 mg/hr and get TONS of fluid off of massively overloaded ARI patients.


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## usalsfyre (Mar 21, 2013)

I really, really like infusions of most meds over bolus dosing if there's any sort of long term component. Fent, versed, NTG, Lasix....much better to be consistent than his peaks and troughs.


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## FLdoc2011 (Mar 21, 2013)

Efficacy wise there's really no difference between bolus dosing and continuous infusion of loop diuretics.  Main advantage is most likely decreased risk of ototoxicity with the continuous infusion.   So if they start complaining of tinnitus or trouble hearing then you may need to make some changes.  

Using a continuous infusion also requires that they were responsive to a bolus dose to begin.  If a bolus dose didn't do anything in terms of a diuresis then a continuous infusion probably won't help.   Has to do pharmacokinetics and drug reaching certain levels of excretion in the tubules to be effective.


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## Merck (Mar 21, 2013)

My concern isn't necessarily the use of a lasix drip (which is virtually unheard of around here) but rather the use in someone who is septic.

All too often I see people given 80, 120, etc of lasix because their not peeing.  A lot of folks need more fluid in, not more fluid out.  Increasing the CO by ensuring adequate volume has a great way of improving renal function.


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## zzyzx (Mar 24, 2013)

What is the mechanism behind Lasix being ototoxic? Can you really cause damage with an 80 mg bolus given by rapid push, or is that a myth?


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## Carlos Danger (Mar 24, 2013)

Definitely not a myth, but quite uncommon and usually transient.

Mechanism is unknown, unless they've come up with something very recently.


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## VFlutter (Mar 24, 2013)

zzyzx said:


> What is the mechanism behind Lasix being ototoxic? Can you really cause damage with an 80 mg bolus given by rapid push, or is that a myth?



I was always taught to give Lasix slow IV push but I have never personally seen ototoxicity and I give Lasix multiple times daily. Like Halothane said I think it is possible but very uncommon. I have seen people practically slam Lasix pushes with no negative effect. When I first started I did the text book slow push but now I tend to give it fairly quick. 

I have also never seen a drastic pressure drops with boluses. The most I have pushed is 120mg


On a side note I hate when cardiology and nephrology consults have chart wars over Lasix. Cards orders Lasix and nephro discounties it and back and forth. After a few days they eventually settle on a dose they can agree on.


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## Summit (Mar 24, 2013)

Chase said:


> On a side note I hate when cardiology and nephrology consults have chart wars over Lasix. Cards orders Lasix and nephro discounties it and back and forth. After a few days they eventually settle on a dose they can agree on.


... and then Pulmonary gets involved and they have their own opinoin...

We made it so that orders are written by the primary team only and all consulting services go through the primary.


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## 18G (Mar 24, 2013)

The patient was a train wreck really. The CHF came first, then came the renal failure from the CHF, and the Sepsis (what they were calling it) from a UTI came as a little bonus.

The nephrologist ordered the dobutamine to stimulate urine output. As I said before, this patient was weeping fluid from the anasarca. She was being transferred to receive dialysis. BUN and creatinine as you can imagine were quite elevated. 

Thanks for the replies and info.


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