IV lasix, hypotension, ICU

AlabamaBelle · Jul 13, 2009

In our unit, pressors = a line. However, just recently, a child was circling the drain and my colleague was lobbying heavily for an a line. BPs were 40/20 with crappy pulses. She got the a line after a little episode of asystole.

If you have pulmonary edema, do give the lasix. Sounds like your patient was already having major issues. We usually give lasix after the blood, but sometimes they need it now.

cardiacRN2006, ADN, RN · Jul 13, 2009

I also usually give the lasix after the blood, but with an elevated K it might be indicated first. Did they order anything else for that K?

Also, what was the levo at? You should have antiicipated the BP dumping after lasix so it's ok to turn the levo up or prepare for another pressor.

Of course, this pt needed an Aline. Everytime I saw that Dr I would have asked for an aline. I would have nagged him/her until I got my way.

Be_Moore · Jul 13, 2009

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

I work in a teaching hospital and I've never not gotten a line. If we can get a cuff BP and the patient is on say 5mcg of levo and that's giving us solid BPs and we don't have to titrate, I may not press the issue. But when said patient has been on Levo for 3 hours and I'm titrating it by manual cuff...it's time for a triple lumen (preferred route for pressors) and an art-line. And usually I don't have to fight it. I call the intern (1st year) and say "Look. We need lines on this dude...I'm titrating pressors, we need a triple and an a-line." And the intern says "Yeah, you're probably right...let me talk to the resident (3rd year)." Then they show up and put in lines. One time I had to remind them to do it for like 2 hours (nagging like) but I still got it on my shift.

Basically, I've never had the problem of a know-it-all intern/resident team that didn't want to be cooperative. Not like the know-it-all attendings I've worked with in the past.

Tait, MSN, RN · Jul 13, 2009

I am not an ICU nurse, but from previous posts it sounds like you were way behind the eight ball and needed more support from your MD's.

Please get some rest :)

:icon_hug:

Tait

caddismt · Jul 13, 2009

Did you titrate your Levo up? Perfuse those kidneys and you can solve a lot of problems.

JustMe · Jul 13, 2009

..... it sounds like you were way behind the eight ball and needed more support from your MD's.
Please get some rest :)
:icon_hug:

:yeahthat:

Just my :twocents:

PostOpPrincess, BSN, RN · Jul 14, 2009

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.

Acute renal failure? (BUN, Creat), on intravascular support (Levo). for pneumonia (?) sepsis?

Pt had a low Hct so i was ordered to give IV lasix and transfuse 1 PRBCs.

Thinking along the lines of intravascular support, RBCS to increase oxygenation, decrease workload, etc., Okay. No problem.

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).

I'm not so sure that was the main problem. If you are at doppler or even auscultation BP, an immediate intervention should've been an Art Line. STAT--patient is on Levophed after all--and that should be the most immediate concern. If you thought the Lasix would help with the potassium increasing than the Bun, Creat must've been fine? If not, then I wouldn't make the assumption that Lasix was the main culprit.

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.

You didn't say if the patient was intubated, or in respiratory distress? Were THOSE (Lasix, Levo) the ONLY factors? Or were there others (i.e. patient wasn't breathing well to begin with.) Hyperkalemia can cause that issue...but again, we're missing some info here. What type of bradycardia? how low? what did you have to do to intervene? Atropine? I need more information.

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?

Not necessarily. This picture, albeit with some good details, isn't the whole thing. I can only make assumptions. You think it might've been, but I am not so sure.

Or should the doctor not have written for lasix in the first place?

Whether or not the doctor writes the order, YOU, the RN, has prudent judgement to NOT GIVE if deemed not GIVEABLE. Does that make sense? There are many a times I haven't followed specific orders and the rationale why. 99% of the time the doc eventually agrees.

Please help me understand what happened. I can't sleep over it.

This will not be the first time you will question yourself nor will it be the last. Next time, go to another nurse whose judgement you trust and ask out loud. It is the safest way; sometimes, another perspective helps clear the air. And also, learn to cope, no one is perfect--if you don't learn you will burn out QUICK.

Now....like I said earlier, I am missing some details so I can't get a good grasp on the preceding events. Guess I'd have to audit the chart itself. Why don't you do that with your educator?

You did your best and if you felt you didn't, learn for next time. And don't be so hard on yourself.

Jo

love-d-OR · Jul 14, 2009

If you had to ascultate the BP, you definetly need an A-line when a patient is on a pressor. Did you have to go in there an ascultate every 15mins? A pressor will buy you a A-line in my unit, there is no if's and but's about it. How do you titrate something like that? About the bradycardia, I really can't answer that one but I'll do some research. I have seen tachycardia but not brady. You also dont mention how high the K was, but I would have given it after the blood. This patient sounds like a mess that needed some more attention by the MD's. It sounds like he might have done better with some dialysis.

Anyway, don't beat yourself down by trying to find where you went wrong. You did your best and next time you will use what you learned from this situation and apply it to the next case. good luck!

suanna · Jul 14, 2009

If the patient was already oliguric you couldn't have caused any harm by pushing the Lasix. If you push it too fast it can cause loss of hearing but I have never seen it cause bradycardia or hyoptension when pushed- later if they have a big fluid dump you can get hypotensive with a reflex tachycardia, but with poor UO and elevated K+, Lasix seems like an OK call- but more likely than not useless since there was poor perfusion to begin with. Getting the K+ down and the urine up was the priority- cells take an hour or more to give, (and to have much of an impact), and lasix can be pushed NOW.

Virgo_RN, BSN, RN · Jul 14, 2009

I know I'm jumping in a little late, but I don't understand how Lasix would cause bradycardia.