Lasix protocols in acute pulmonary edema

[sledogg1]

Could have used it the other night on a call....but it wasn't my shift Used PEEP twice last summer on drowning's and it was sweet to hear the difference and complience of venting. The new bag valve masks in which u just screw on the PEEP on the side and medication port is handy.

[scope2776]

i guess if you had to draw a line in the sand it would be 100 sys. this is of course up to the medics judgment. i would be a little more cautious with lasix than i would with 0.4 mg SL nitro. A single nitro spray i can correct with fluids pretty quickly, lasix will last quite a bit longer.

[SnowFlight]

You raise a great question, as most don't realize that the mechanism of action Lasix exerts goes beyond just diuresis. The decrease in venous tone and increase in venous capacitance within about 5min of IV administration is just as important (and potentially exacerbates hypotension). You may have a hard time finding exact numbers to correlate with the risk/benefit of giving lasix, but going back to diuresis for a sec I would like to answer your question with one of my own that could help guide your clinical decisions.

What pressure is required to perfuse the kidneys and allow diuresis to occur?

The Renal Perfusion Pressure (RPP) must be maintained at a level which allows the kidney to function. This means different things to different people depending on underlying kidney pathology, chronic hypertension, drug use, etc.. A good guesstimate in a healthy person is that if they have a Mean Arterial Pressure (MAP) of somewhere lower than 60-70mmHg you can expect that they are not adequately perfusing their kidneys. Therefore their Glomerular Filtration Rate (GFR) will drop and they wont be making much urine. For people with renal pathology or chronic HTN their kidneys will be accustomed to even higher pressures and may require even higher MAP's.

Long story short, don't count on Lasix as an effective treatment in the hypotensive acute pulmonary edema patient. If you are worried about their blood pressure, you should be more worried that the drug can't exert its mechanism of action at all.

clear as mud?

[tniuqs]

Some interesting points here....there is really no line to be drawn in the sand, Snow flight makes very good sence as in regards to RPP, we have dicussed the use of Inotropes ie Dopamine "Pumped Please" for cases of hypotension associated with pulmorary oedema and lots of links in the search engine.

cheers

[sledogg1]

Dopamine pumped??????????? no way man, here in NS down to a science. Take care Tniugs.......now come to the dark side and eat lobster. CHEAP

[Connie31079]

Cheap Lobster? where??????????? $8.99 a pound here.....i certainly don't find that CHEAP! LOL!

[Urbanmedic461]

Only a bottom limit for Nitro- 150 systolic with no line in place.

B.S.: Systolic for Nitro is 100, not 150, 100 is National Standard and is taught in every EMT-B class that I know of.

No mention of line in place.

Well I wouldn't be calling B.S. (as you called it). Ontario provincial protocols are 140 systolic and above for NTG (for pulmonary edema) without a line in place. Now with chest pain it is 100 systolic min. The 140mmHg systolic is not uncommon practice when using NTG for pulmonary edema.

Relax a bit.

[sladey67]

100 mmHg systolic here.

What doses does everyone give?

[scratrat]

Ours is 100 mmHg for both lasix and NTG.

As a side note, our current dose is 1 mg/kg. Rumor has it they may lower that to a straight 40 mg across the boards, but nothing in stone yet. They are supposed to be updating our protocols in the next 1-2 months.

[sladey67]

We use 40mg, unless they are already on oral diuretics then they get 80mg. One repeat after 10 mins if no improvement.