Lasix and CRF

[WonderRN]

So I am still a relatively new nurse, and I have a question about Lasix and CRF....

I had a patient last night that had pulmonary edema secondary to ESRD. His last dialysis was just the day before, his lungs sounded pretty cruddy, he required the non rebreather for a bit, but then was able to keep his O2 sats at 95% on 4L per NC at rest, in High fowlers. He was hypertensive at 190/90.

This patient told me he only urinated once every 2 weeks... the doc ordered 60mg Lasix IVP. I questioned his order, told him nicely that the patient hardly made any urine.... he still wanted me to give it.

I am missing something here? I thought the whole point of loop diuretics was to stimulate the kidney to make more urine, and if your kidneys really don't do that....... ?!?

We also gave him an inch of nitro paste..... I am used to using nitro, usually a drip, to decrease preload in these patients.... his pressure certainly could support it....

Suggestions/feedback?

[Emergency RN]

Aside from its loop of Henle action, Lasix also had vasodilation effects that can help decrease preload.

[nurse2033, MSN, RN]

Yeah, what ERRN said... You were right to question (call it clarify) with the MD. A nitro drip might have been better choice but it is their license to practice as they choose. Don't forget that 50% of all MDs were in the bottom half of their class.

[WonderRN]

aaahh....ok, thanks!

[Richard_Head]

Lasix is not particularly helpful in this situation. Yeas lasix works in the Loop, if I recall it acts at the Na-K-2Cl cotransporter. It will not trick dead glomeruli into working. It is also probably not harmful. Nitroglycerin is a venodilator but a person in CRF has usually lost their ability to compensate via venous capacitance so NTG would be of minimal value. Dialysis with fluid removal is the is the answer to this problem.

[Sun0408, ASN, RN]

I work a renal floor and only pts with ARF are given lasix on our floor (if kidney function can handle the drug).. For our CRF pts they are sent to hemo to remove the fluid.

[Emergency RN]

yeah, what errn said... you were right to question (call it clarify) with the md. a nitro drip might have been better choice but it is their license to practice as they choose. don't forget that 50% of all mds were in the bottom half of their class.

well, that's not half bad. i remember an older doc once shouted, "...rotating tourniquets, stat! * " at a bedside and all the rn's under the age of 50 stared at him blankly, not knowing what he was talking about, lol... damn, but i feel old

*rotating tourniquets was a method thought to mechanically drop preload, and used to treat acute pulmonary edema. it was the subject of much dispute as there was no clear research evidence that it was ever effective, with some findings in fact, suggestive that it didn't work at all. it has since fallen from favor as health care practice has shifted more towards chemical adjuncts (meds like morphine, nitroglycerin, lasix).

[Lunah, MSN, RN]

Thanks for explaining, because I had NO CLUE what rotating tourniquets meant. I think I'll try mentioning it to some of our more "experienced" nurses when I go back to work tomorrow.

[traumaRN1908, RN]

In addition to reducing the preload, the vasodilation effects of the Nitro paste will also dilate the pulmonary vasculature allowing some of this fluid to be pulled from the 3rd space and the subsequent Lasix will assist what little renal function is left to help excrete the fluid. In some cases, even though the patients normally do not make a lot of urine, this can cause more to be excreted. Additionally, if no urine is made, the effects of these drugs may improve oxygenation, and help to keep the patient off of BiPAP/NRB until the fluid can be removed by hemodialysis.

*I learned this after having a discussion with one of my Attendings for the same type of situation.