Sepsis and Lasix

jadelpn, LPN, EMT-B · Jun 24, 2012

Yes, I would at least bring it up, as some doctors are more apt to give it then others. However, crackles in itself doesn't mean excess fluid needing lasix. If patient had edema and other signs of fluid overload, then certainly. However, pulmonary toilet by respitory could determine more quickly if it is a mucus thing or a fluid thing.....

Esme12, ASN, BSN, RN · Jun 24, 2012

The other night, I had a pt in Med-Surg admitted at 0030 for PNA and sepsis. BP on arrival was 140/[can't remember], O2 sats were low 90s on 3L, pt was very painful on her lt side w/coughing. PE study was negative, CXR revealed Lt lower PNA. This pt has COPD and still smokes, uses O2 at home at night, LS were dim in the upper and I heard very fine crackles in both lower lobes upon admission to the floor. Diagnosis was PNA and sepsis, WC 18. I don't recall CHF being part of her health hx, but I think HTN is.
She slept for most of the rest of the night, no dyspnea. I went to do her AM vitals, BP was 114/70(?). After that, around 0600 she had a coughing episode, I called RT to come give a neb tx. When that was finished, RT says to me, "She has crackles in her lungs. She needs Lasix". I told him I'm not sure that's indicated right now, since she was admitted for sepsis and her BP seems to be trending down.
Was my reasoning on track here? Would Lasix have been a good option for the pt? I know sepsis and diuretics can coexist, but there has to be a delicate balance. And I assumed the fine crackles I heard were r/t the PNA, not fluid overload.
Should I have brought Lasix up to the MD?

Several questions come to my mind. What were the lungs sounds before the neb? Did the neb help the cough? What were her sat"s at this time? What did you hear in her lungs after the treatment....where the lungs better or worse? Was she on IVF? If she was on IVF what was the rate? Did she get any fluid in the ED? If so how much?

What was her normal B/P? A 140/s on arrival to 114/s while I would consider it in my decision making process I am not that concerned that it is lower than on admission....the ED is a stressful place. Why the diagnosis of sepsis? Her WBC is only 18......not very impressive. Sometimes they "jack up" the admitting diagnosis to help with admission reimbursement/approval.....PNA with Sepsis makes the patient "sound sick enough" for admission.

Is the patient going to have am labs? If so and she is feeling better I would wait for the labs. If she's not better and has a ton of fluid I might call. So, depending on the assessment/answers I would decide whether or not to call. But.....when in doubt, call the MD. That is what they get the big bucks for..... :smokin:

tokmom, BSN, RN · Jun 24, 2012

What they said. I don't think I would wake up an MD for a lasix order, but let him see the pt in the morning. It would not be first and foremost in my mind at this time. I would do what the others said. Use some pulmonary toileting, nebs and see how they sound afterwards. Of course this depends on any IV fluids, rate, labs, etc.. as well. If the pt had been given too much fluid in the ED and hasn't peed and the IV is still chugging away, I might be a wee bit concerned about fluid overload. But from what you told me...I would not.

opossum · Jul 4, 2012

Thanks, everyone, for the responses.

I agree that I wouldn't have called the night hospitalist, since the day MDs were going to do their rounds soon anyway. What I think I should have done (at the very least) was retake her BP and update the oncoming RN, or page the AM doc with an FYI about the BP trending down and crackles in the lungs.

Wonder how it all turned out...I haven't worked on the floor for a week or so :)