Lasix vs Bumex

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    Hello! The other night I had a pt with end stage renal failure, anuria, hemodialysis. He was on a vent, doing fine, and then his SaO2 dropped very fast and we had hard time to bring it back. He also had extensive cardiac history, including CHF. STAT CXR was mostly whited out. Weird, because he didn't even had any fluids going. I even stopped his sedation with KVO because we planned to extubate him in the morning. He also had dialysis that day. The doc gave a bunch of orders, including morphine (to calm him down and stop air hunger? the pt was somewhat awake by then), nitro drip (do dilate blood vessels in the lungs?) and Lasix IV push. With Lasix I was puzzled. I read that Lasix is contraindicated to pt with anuria. Besides, how would we get read of the fluids from the lungs if all the fluids are going to stay in his system anyway? He is not going to produce urine to get rid of his pulmonary edema. I asked the doc about it, but he only gave me the look as he is one of those who are too good to answer some nurse. I cannot find anything on-line and other nurses didn't know why either. My only guess is that Lasix would shift fluids from lungs into blood vessels and maybe the doc was planning to send request for a dialysis next day? Anybody has more clear understanding of it?
    I appreciate any reply!
    sammiejane33 likes this.
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    Lasix wasn't going to shift fluids anywhere. It could work, if patient still had, say, 10 - 15% of GFR and not producing any urine not because his kidneys are totally dead but because other issues (such as mentioned CHF).
    There is a thing named "Lasix trial" for anuric patients, especially severely sick and dialysed, because in such case estimations of GFR are imperfect, to say the least (due to fluid shifts, hemoconcentration, periodical remove of wastes by dialysis, etc). If Lasix works, even a little, it generally means that kidneys are still able to filtrate (that part of making urine dies the last) and so this way of fluid removal is possible. If it doesn't, then Nephrology service will have to know because only they can do something to get the water out of the patient. Nitro was for probably for supporting the myocardium to sustain cardiac output high enough to get some blood for kidneys, among other things. If LVEF was very low, the patient could go to anuria for this reason alone.
    sammiejane33 likes this.
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    Quote from markgolfa
    Hello! The other night I had a pt with end stage renal failure, anuria, hemodialysis. He was on a vent, doing fine, and then his SaO2 dropped very fast and we had hard time to bring it back. He also had extensive cardiac history, including CHF. STAT CXR was mostly whited out. Weird, because he didn't even had any fluids going. I even stopped his sedation with KVO because we planned to extubate him in the morning. He also had dialysis that day. The doc gave a bunch of orders, including morphine (to calm him down and stop air hunger? the pt was somewhat awake by then), nitro drip (do dilate blood vessels in the lungs?) and Lasix IV push. With Lasix I was puzzled. I read that Lasix is contraindicated to pt with anuria. Besides, how would we get read of the fluids from the lungs if all the fluids are going to stay in his system anyway? He is not going to produce urine to get rid of his pulmonary edema. I asked the doc about it, but he only gave me the look as he is one of those who are too good to answer some nurse. I cannot find anything on-line and other nurses didn't know why either. My only guess is that Lasix would shift fluids from lungs into blood vessels and maybe the doc was planning to send request for a dialysis next day? Anybody has more clear understanding of it?
    I appreciate any reply!
    Was it cardiogenic or non cardiogenic pulmonary edema? You dont think the pt was fluid overload and The SaO2 dropped very fast? My guess is pt might have a bad mucus plug and developed non cardiogenic pulmonary edema but I could be wrong. Breathing through closed airway can create negative pressure inside the lungs and thus draw fluids inside the lungs and eventually pt develop non cardiogenic pulmonary edema. It's like pulmonary edema secondary to bronchospasm post extubation.

    "The doc gave a bunch of orders, including morphine (to calm him down and stop air hunger? the pt was somewhat awake by then), nitro drip (do dilate blood vessels in the lungs?) and Lasix IV push. With Lasix I was puzzled. I read that Lasix is contraindicated to pt with anuria."

    They normally give morphine primarily to decrease preload (it can also decrease the afterload) and to alleviate anxiety (decrease O2 demand). IMHO,Nitro drip is to decrease preload by venous dilation and not to dilate blood vessels in the lungs. I agree with you on the Lasix order,it doesn't make sense because the pt is anuric secondary to ESRD. But some nephrologists believe that Lasix causes a rapid venodilatory response (starts before an effect on diuresis). They believe that rapid venodilatory response has significant effect on preload.


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