[Emmanuel Goldstein]

I had an order to start a continuous furosemide infusion. My specific concerns were that the patient was not on any form of monitoring and that the initial dosage seemed to be rather high.

In every other facility I've worked, med/surg patients on these drips were required to be placed on remote tele, and there were also specific policy guidelines regarding how often to monitor VS, weights, I/Os, and labs. There were also guidelines as to the initial dosage and rate of titration and these rates were calculated on the patient's dry weight.

None of this existed here. In fact, when I questioned the chief pharmacist she stated that although "we've talked about it", the hospital didn't have a policy on continuous Lasix infusions (there was even some initial confusion as to whether pharmacy or nursing mixed the bag). In response to my questions about the above monitoring (other than tele--- this floor wasn't set up for tele), the answer was a vague, "well, we will watch her closely" followed by an admission that there were no guidelines for doing so. The starting rate of infusion was much higher (about 3 times) than I've seen used in the past, and the answer to my question on this was simply, "yeah, that's pretty high, but the patient has received intermittent bolus doses".

I'd like some input from others here regarding their hospitals' policies on these infusions. I tend to be a pretty easy-going person, but this just seemed wrong on so many levels.

[Angie O'Plasty, RN]

I understand that you'd be nervous without a policy in place regarding a drip like that. Lasix gtt patients must be on telemetry at our place.

Seems to me that any patient on a lasix drip should be monitored, not just for tele, but with appropriate daily labs and ototoxicity. I would also check out the monograph on lasix for their recommended dosing guidelines.

http://www.globalrph.com/diuretics.htm

[GilaRN]

What was the dose, if I may ask. Are you able to discuss the patients history?

Without specifics on the patient's condition, I would agree that close monitoring would be indicated. In addition to blood pressure changes, changes in serum potassium levels could be a concern with large doses of lasix. This alone would be a good rationale for initiating cardiac telemetry.

[Emmanuel Goldstein]

Exactly, Angie.

Thanks. While I don't mind looking foolish, and Lord knows I'm old enough not to care about that, I was just curious if my concerns were valid.

This seems to be an incident just waiting to happen.

To Gila... the initial starting dose was 20mg/hour. (1:1 drip)

This patient had chronic issues with mag and potassium depletion (even without lasix), and was in some mild renal insufficiency. Her baseline BP tended to run on the low-normal side (100-110/50-60). The reasoning behind ordering the continuous infusion was because she wasn't responding to intermittent bolus dosing. Another issue I have with all of this is there was never a nephrology consult obtained on this patient.

[Emmanuel Goldstein]

Originally Posted by Angie O'Plasty, RN

http://www.globalrph.com/diuretics.htm

Thanks for the link! Great site. According to this, she was being started at a little over 3 times the dose recommended here:

Continuous I.V. infusion: Initial IV bolus dose of 0.1 mg/kg followed by continuous I.V. infusion doses of 0.1 mg/kg/hour doubled q2h to a maximum of 0.4 mg/kg/hour if urine output is <1 ml/kg/hour. Other studies have used a rate of 4 mg/minute as a continuous IV infusion.

[tencat]

Correct me if I'm wrong, but that sure sounds like a recipe for disaster. If it were me, I would take the issue to the next level (charge nurse?) and oh so politely refuse to carry out the order without specific parameters. It's not safe to carry it out the way it's currently set up. If the patient has already had issues with low potassium, continuous lasix administration is not going to help matters. Any potassium runs scheduled too? Plus the whole ototoxicity issue is a concern. Wow, there's just so much wrong with the whole situation.....

[Emmanuel Goldstein]

Originally Posted by tencat

Correct me if I'm wrong, but that sure sounds like a recipe for disaster. If it were me, I would take the issue to the next level (charge nurse?) and oh so politely refuse to carry out the order without specific parameters. It's not safe to carry it out the way it's currently set up. If the patient has already had issues with low potassium, continuous lasix administration is not going to help matters. Any potassium runs scheduled too? Plus the whole ototoxicity issue is a concern. Wow, there's just so much wrong with the whole situation.....

The charge nurse didn't have any concerns with the order. No potassium runs. No potassium or mag ordered routinely (not even po). The patient is on daily CMPs, and receives repletion as needed. Of course, with a continuous drip and considering how long it takes between the draw and results on routine lab runs (not to mention the time taken paging the doc and receiving the orders), the lytes would not be accurate anyway. My last hospital's policy on these drips was to obtain CMP initially, then every 4 hours for the first 24, then every 6 hours while the infusion continues. We had prn orders for sliding scale K runs. There were also specific parameters regarding other monitoring, weights, I/Os, etc.

[cmo421]

Originally Posted by Angie O'Plasty, RN

I understand that you'd be nervous without a policy in place regarding a drip like that. Lasix gtt patients must be on telemetry at our place.

Seems to me that any patient on a lasix drip should be monitored, not just for tele, but with appropriate daily labs and ototoxicity. I would also check out the monograph on lasix for their recommended dosing guidelines.

http://www.globalrph.com/diuretics.htm

great site. Valid concerns. Lasix drips r great,but should be watched and on a pump of course. Tele is recommended due to possible eletrolyte issues. It should be regulated according to U/O and labs. Foley is required in most cases. Urine lytes and osmo's and a serum osmo at the min should be done q4-6 hrs,with lytes q6 also. I would refuse to hang a drip without the doc giving specific guidelines and concurrant labs. Asked nicely of course!,,lol. Parameters should be written in the MAR for all to see also.

[Emmanuel Goldstein]

Originally Posted by cmo421

I would refuse to hang a drip without the doc giving specific guidelines and concurrant labs. Asked nicely of course!,,lol.

I didn't hang it. It was an early morning order, and it fell to the nurse on days by the time all this was sorted out. Not that I believe it was sorted out. But the nurse following me did not share my concerns. So I suppose she went ahead and started the drip.

[santhony44]

I've been out of the hospital for a while, so I have never heard of a furosemide drip.

Do they really work when bolus doses don't?

I think I would share your concerns about monitoring the patient and labs, BTW.