Pressors with diuretics

[psu_213, BSN, RN]

A couple months ago we had an elderly female patient in our ED. Among other issues, she came in with fairly low pressure (SBP in the 80s). Given a few boluses of NSS despite a H/O CHF. Ended up intubated. RT started suctioning white, frothy sputum from the ET tube. Fluids were stopped, BPs not better--a pressor was started. Someone suggested Lasix to the doc. His reply "no we can't do Lasix with that pressure." With the pressor would be OK to give lasix? Pretty obviously, this lady was fluid volume overloaded with pulmonary edema. Need some help from nurses with more experience with pressors. Thanks in advance.

[MunoRN, RN]

This is where a CVP can be useful. It's possible for a patient to have excessive fluid outside of their vascular space, such as wit pulmonary edema, but still have insufficient fluid intravascularly. The basic goal of any pulmonary edema treatment is to move the fluid back into the vascular system. Lasix increase excretion of intravascular fluid, allowing fluid in the lungs to return to the vascular system. Morphine and NTG vasodilate which also allows fluid to return to the vascular system. If the patient is intubated then increasing the PEEP will help keep fluid in the vascular system.

My preference in the situation you describe would be to give albumin. This would maintain or even improve the patient's intravascular volume will also keeping fluid out of the lungs. Decreasing pressors as much as possible would also allow for more fluid to be stored in the intravascular space until it can be removed.

[Anna Flaxis, BSN, RN]

I was going to say albumin! Woot woot!

[CraigB-RN, MSN, RN]

Pressor is a big category. What specific vasoactive were you using? I don't want to assume that the problem of the BP was cardiac output vs a tube problem like sepsis. Lots of different issues. Could be a where the fluid is problem and not an amount of fluid.

Over the years I've done some pretty strange things. Lasix, fluid bolus, dobutamine. doing a juggling act all night.

You might also find that the positive pressure works to help move the fluids out of her lungs.

[psu_213, BSN, RN]

What specific vasoactive were you using?

I believe it was norepi…it was a while ago, so I could be wrong.

Incidentally, this woman had many medical problems…CHF, kidney issues (although I think they were more AKI than chronic failure), diarrhea x weeks--which caused dehydration and the kidney injury, CA with chemo, etc., etc.