[AB_Normal]

I am an east coast Paramedic working my way through nursing school in my local ER. I perform Critical Care Transports. I want to gain valuable experience prior to taking on the responsibility of being an RN.

During my skills assessment and oral boards I was given a scenario by the Medical Director that has be somewhat puzzled. My pt was in severe respiratory distress secondary to acute pulmonary edema. The patient's meds included hydrochlorothiazide as the diuretic. We only carry Lasix on the truck. The Medical Director asked me my treatment of the patient. I gave him the standard protocol answers of O2, IV, EKG, NTG...but when it came to diuresis I was a bit stuck. Even though I know what hydrochlorothiazide was...I didn't know if there was a conversion type dose vice standard dose of Lasix. I was honest and stated that while I wasn't sure I would call the on duty MICN or MD. He liked that answer...but still wanted an answer if 'push' (pun intended) came to shove. I gave him the dose of 40mg-80mg Lasix..erring on the side of the lower dose.

I have not been able to corner the Medical Director since being hired to find the correct dosing. Doc's can be somewhat busy in the ER. LOL! I have researched the Internet to see if there is some sort of conversion factor. I have some understanding of how each works for diuresis. Would someone enlighten me?

[chris_at_lucas_RN]

Have you thought of asking the pharmacist, since the doc is hard to get a hold of?

[TMPaul]

Originally Posted by AB_Normal

I am an east coast Paramedic working my way through nursing school in my local ER. I perform Critical Care Transports. I want to gain valuable experience prior to taking on the responsibility of being an RN.

During my skills assessment and oral boards I was given a scenario by the Medical Director that has be somewhat puzzled. My pt was in severe respiratory distress secondary to acute pulmonary edema. The patient's meds included hydrochlorothiazide as the diuretic. We only carry Lasix on the truck. The Medical Director asked me my treatment of the patient. I gave him the standard protocol answers of O2, IV, EKG, NTG...but when it came to diuresis I was a bit stuck. Even though I know what hydrochlorothiazide was...I didn't know if there was a conversion type dose vice standard dose of Lasix. I was honest and stated that while I wasn't sure I would call the on duty MICN or MD. He liked that answer...but still wanted an answer if 'push' (pun intended) came to shove. I gave him the dose of 40mg-80mg Lasix..erring on the side of the lower dose.

I have not been able to corner the Medical Director since being hired to find the correct dosing. Doc's can be somewhat busy in the ER. LOL! I have researched the Internet to see if there is some sort of conversion factor. I have some understanding of how each works for diuresis. Would someone enlighten me?

HCTZ only comes in tablet form. Not the best choice for rapid diuresis. Lasix, however, comes in PO and IV form, with the latter used for rapid diuresis.

[RN92]

Im with TMpaul.I work in the ER. Hctz would take too long. You would need to use Lasix IV. The paramedics usually give the lower dose of 40mg just to get diuresing started. Once the pt gets to the ER - they (the er doc) will get more aggressive. You dont need to give too much Lasix without knowing what his labs look like.

[rjflyn]

Well from my past medic experence 40mg Lasix was typical a dose we gave to diuretic 'virgin' patients, and in fact have given as much as 200mg in a single dose and often times even this doenst work to well.

Also while not exactly HCTZ there is IV Diuril- chlorothiazide, we use it in our PICU patients alot, and true it is not fast acting and we have used it in continuous drips as well.

Rj

[Gompers]

Agree with the above posters. While I do work neonatal, we often give hydrocholorthiazide (combined with spironolactone) oral suspension BID to our babies with chronic lung damage to prevent wet lungs. However, if the baby is having any respiratory distress and we know by X-ray or ascultation that it's due to pulmonary edema, we will give either oral or IV lasix for a quick fix. If the baby is sick enough to need an IV we'll just give the fast-acting IV form, but if the patient is stable enough that there's no IV we still find that the oral form of lasix works much quicker than the hydro/spiro suspension. Then we'll usually give just the lasix once or twice a day for three days to really fix those lungs, and after that restart the hydro/spiro BID.

As for dosing, I don't believe there is any conversion between the two meds. I'd just give the lowest dose available, I suppose, because they can always give more later on. We give anywhere from 0.5mg-2mg/kg - peds dosing. For adults, I believe it's anywhere from 20-80mg IV per dose.

[critcarenurse16]

Lasix 40 mg is a good start, and I agree with the poster that the ED doc will get more aggressive once in his hands.
I have seen docs give doses up to 300 mg but if you're getting this high I think its time to try a new drug. Bumex is another loop diuretic that often works when Lasix does not--and vice versa. For continued diuresis a good combo therapy is IV Lasix followed by zaroxolyn PO.

[Dinith88]

Originally Posted by critcarenurse16

.
I have seen docs give doses up to 300 mg.

Man thats a huge dose. Should make it an even 500mg and call it a day

I agree with the above poster that stated a low dose is in order until knowing a pt's lab work. A hefty dose of iv lasix can 'burn-out' a pt's renal function..especially if a pre-existing insufficiency(or dehydration) exists. Without labs and x-rays, a paramedic-made diagnosis of 'pulmonary edema' may be wrong...and iv-lasix can really miff the pt's kidneys. but i suppose if an emergent situation exists, chances need to be taken...(40mg would probably be a good 'compromise' dose. A bigger dose probably wouldnt be more 'effective' than 40 prior to arrival in the ed anyway..unless of course the hospital is FAR FAR away.

The biggest lasix dose iv seen (more than once) was 100mg ivp bid. This was on decompensated stage IV CHF'ers who were already receiving gigantic oral doses (and usually more than one diuretic)...these pt's usually have renal involvement at this point..and are nearing ESRD and the need for dialysis.

300mg? was this a last-ditch effort in an emergency?..prior to emergent dialysis??