IV Bumex in Home?

pennyaline · Jan 15, 2010

Background: elderly fragile CHF pt with weight gain of over 10# in 1 week since admission, tight lungs with bibasilar crackles, 3+ BLE pitting edema, regular meds include Bumex 2 mg PO BID.
Today, doc orders additional 3 mg Bumex IV push x 3 days (over the weekend) to be given in addition to regular PO dose. Pt does not have any K+ replacement ordered and no labs ordered. That's a total of 9mg/day of Bumex without K+ replacement and no metabolic labs ordered. What say you experienced nurses?

Are you sure it's a total of 9mg Bumex daily for three days? I got 7 mg (2mg po BID = 4mg total daily po, plus 3mg IVP qd = 7mg qd).

How long has the doctor been treating this patient? What is her medication history? What other meds is she taking to date? What other diuretics have been used thus far? Has Bumex been used in conjunction with potassium-sparers in the past? Was it successful? What are her lytes now, before treatment? When does the doctor want to see her again? Were lytes ordered to be done after the weekend?

So many questions! If this were a new patient for me, though, I would be on the horn to the doc for lab work orders to be done before starting IV Bumex and follow up labs on Monday -- at least.

KateRN1 · Jan 15, 2010

Ack, you're right, 7mg. Math was never my best subject. Still, a higher dose than I have ever seen in hospital, let alone home care. Doc knows her well and is basically tired of dealing with her. She's been in and out of hospital at least half a dozen times over the last 3-4 months. She's been on Lasix, 40 or 80 PO BID, I forget which. I don't think they've tried K+ sparing, but don't know for sure. Current lytes are unknown and no BMP orders to follow up with. She seems to be pretty refractory, not diuresing well with the PO Bumex, certainly didn't with the Lasix. However, if we meet her threshold for the Bumex and she has a major diuresis, it will be long after my visit and I'm worried about a bunch of issues, hypotension, hypokalemia, dysrhythmias, ototoxicity, renal toxicity, hepatotoxicity, etc. I don't feel safe giving this amount in the home. Neither my director nor clinical manager have recent home health experience (or hospital for that matter) and I feel they are more worried about losing referrals from this doc than what could happen with this patient.

southernbeegirl, BSN, RN · Jan 15, 2010

bumex IS a potassium sparing diuretic isn't it?

CrufflerJJ, BSN, RN, EMT-P · Jan 15, 2010

bumex IS a potassium sparing diuretic isn't it?

It can cause hypokalemia, so I don't think so. Definitely not like spironolactone. Pt may need supplemental K.

Virgo_RN, BSN, RN · Jan 15, 2010

bumex IS a potassium sparing diuretic isn't it?

Bumex is a loop diuretic, in the same class as Lasix.

10mg/24hr is the maximum recommended dose, so at 7mg/24hr, this patient is within the safe dosing guidelines.

Can you call the doctor and ask for a potassium supplement?

KateRN1 · Jan 15, 2010

I can ask for the K+, but my concern is that the patient will be essentially unmonitored. This is home health care--I go in, do visit, give med, and leave. If we pass her refractory threshhold for the Bumex and she has a major diuresis, she is at risk for all the things mentioned above and there will not be anyone there to address the issue. She has family in the home but they are not healthcare providers, and while I can teach them what to look for, all they could do is call EMS and wait. Pt's last admission was acute-on-chronic renal failure secondary to CHF exacerbation. Is this dose going to worsen her renal funtion? It's also hepatotxic at high doses and we have no documentation of liver function.

Another thing to think about: if 1 mg Bumex = 40mg Lasix, this is the equivalent of giving 280 mg of Lasix IV push. And then leaving. It just doesn't feel right to me.

Virgo_RN, BSN, RN · Jan 15, 2010

I think it would be fair to call the doctor with your concerns. Perhaps this lady should be in the hospital.

Wishinonastar, BSN · Feb 1, 2010

Instruct her in the S/S to watch for, you are seeing her daily, right? You should be able to pick up on anything that is of concern. She can always call for a nurse to make an extra visit. Sounds like this patient is not reponding well to oral meds, the IV does may be just the thing to get her going. We have done this many, many times in home health. If she is tolerating 4mg po daily I don't think that the 3mg extra each day is going to cause a profound difference, but you can always ask for labs, and generally they do order labs to be done after the 3 days of IV doses. When was your last labwork? How was her K+ then???