IV lasix, hypotension, ICU

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Hi, I am a new grad in an ICU. Had this one pt who was on levo, coorifice lung sounds, edematous with no urine output, extremely high K. Pt had a low Hct so i was ordered to give IV lasix and transfuse 1 PRBCs. At the time I didn't think much of it. I thought lasix would help with the urine, decrease K and prevent further fluid overload esp. with the blood. I just didn't happen to think of the BP (no arterial line, machine wasn't picking up BP--either from the edema or it was too low--and needed to ausculate for BP). Well right before I hung the blood, I gave the lasix. Few minutes after pt brady'ed down and we couldn't get a BP. Was this because of the lasix I gave? Looking back now I know I should have given the Lasix after the blood or maybe not even at all. Was it my messing up that caused the pt's condition to worsen? Or should the doctor not have written for lasix in the first place? Please help me understand what happened. I can't sleep over it.

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Usually in my unit if we give blood we give the lasix after the unit is transfused. When the doctor ordered the blood did he know about the hypotension?

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Specializes in Pulmonary, MICU.

If patient was already suffering from pulmonary edema, patient needed lasix..especially with packed cells coming. What the patient really needed was an art line. If a patient needs pressors, they probably need a line. If a patient has no BP with a cuff, patient definitely needs a line.

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I had suggested an A line but the Md didn't want to put one in. But is it possible that because I gave the lasix before the prbcs that it made him brady down?

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Specializes in Pulmonary, MICU.

Not likely. Was the patient perfusing? And the MD didn't want to put one in..was the MD on crack? Did you try getting a palpated manual BP?

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before the bradycardia, yes perfusing. after..no--pt was unresponsive..not sure why no art line. i just can't seem to figure out the cause of the bradycardia/junctional rhythm. any insights?

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Specializes in Telemetry, CCU.

I'm not sure but maybe the brady could have been caused by either the potassium level or maybe the Levo caused a reflexive brady? I know that Neo causes reflexive brady, not sure if Levo does. Honestly with the way that pt sounds, I don't know that giving the Lasix before or after would have made that big of a difference but usually we give it after the blood, with the rationale being that you just gave the pt extra fluid and the Lasix will help them clear it. That pt sounds like maybe he needed it before he even got blood, however, it also sounds like his kidneys may already be shot and the Lasix may not have even helped at all.

Just curious, did the pt pee from the Lasix? Or was he already acute renal failured?

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Specializes in Pulmonary, MICU.

The peak effect of lasix is 30 minutes after IV administration, so you have some definite time to play with administration times.

Norepi can cause a reflex brady, but it should still be a sinus brady.

Junctional sounds like the K+ was to blame. With elevating K+ levels you will see tall peaked t-waves, widening of the PR interval and eventual junctional rhythm at high levels.

And I agree with above. High K+ levels make me wonder if the kidneys were already trashed to begin with such that lasix wouldn't do anything. Maybe the patient needed a little of the nasty brown juice and some IV insulin and D50.

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I don't work in ICU but I've given lots of IVP lasix and never had a patient brady down (watch it happen next time I work). So I would think based on the clinical picture you painted, the patient was already fubared, maybe on their way to multi system failure, and the lasix would've helped or not done anything at all based on the level of renal function. Possibly like the other pps said levophed which can decrease cardiac output I think (correct me if I'm wrong) or the Kt level.

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I hope your patient got an arterial line after that.

I have seen bradycardia due to respiratory issues. Improve the oxygenation, and the heart rate comes back up. Maybe your patient was having resp. distress when all this was happening?

I would have given the Lasix first. A high potassium is something to be treated as soon as possible.

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I think ya'll are right. K+ most likely the culprit. Thank you all!

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Specializes in COS-C, Risk Management.

Was this in a teaching hospital and the patient being treated by a resident?

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