Lasix – Number 33 out of 33 on my Essential Drug List. (Note: Only 8 of the 33 will be ultimately deemed essential.)
Dear EMS Medical Control-
I am an 87-year -old man with pneumonia and sepsis laying in a hospital bed, feeling rather miserable. Two days ago one of your paramedics gave me Lasix believeing the junky sounds in my lungs were a sign of pulmonary edema. He was wrong. As a consequence my blood pressure dropped from 170/90 at my house to 90/40 in the ED where they gave me two liters of fluid in addition to several very strong antibiotics, and I am told my kidneys are not functioning so well. I know I am old and approaching the end of my life, but I was once a vibrant man who taught school for many years and often demonstrated for various causes such as civil rights and against the slaughter of baby seals. If I were able, I would make a sign and demonstrate in front of your house. I would lean against my walker and hold my sign up for passing cars and the news cameras to see. “Stop the Horror! Ban Lasix!” I know I am not the first victim. I wish to be the last. Those of us with pneumonia and sepsis are sick enough without Lasix making us worse.
As you know for the last year I have been a clinical coordinator at a local hospital. Our EMS Medical Director and I have had lengthy discussions about taking Lasix off our sponsored services’s trucks. The problem is we are part of a larger region and we try to do all our protocols regionally. The region just finished up its 2009 protocols, and won’t be addressing changes until later this year with an implementation target date of sometime next year. We both agree we should take Lasix away. We don’t want to act unilaterally. But I am thinking (with each imaginary letter we recieve) that maybe we ought to act now.
In 2006, a study appeared in Prehospital Emergency Care that revealed that Lasix was given inappropriately to 42% of prehospital patients.
For the last two years I have been keeping track of all prehospital use of Lasix from our various sponsored services using similar criteria to the mentioned study. I have found a 37% inappropriate rate, a rate that has improved only marginally with education.
Looking closely at the patient data, it is clear just how difficult the diagnosis can be (lacking a chest X-ray and a BNP blood test). The indicators that many of us were taught in paramedic school don’t always hold up. Some patients with fevers had CHF, while some patients who were not febrile had pneumonia. Some patients on Lasix had pneumonia and some patients not on Lasix had CHF. Some pneumonia patients had significant edema and some CHF patients didn’t have any edema. The only sign that at all was suggestive of CHF was blood pressure. In general if a patient had a BP over 170 systolic they were more likely to have CHF (Except for patient X here). Speaking of blood pressures when I tracked BPs in the ED, nearly every patient, CHF or not, who received Lasix prehospitally experienced a huge (although sometimes transient) BP drop in the ED.
I know about misdiagnosing CHF myself. In 2006, the very day after reviewing the before mentioned article at a journal club meeting, I had a patient in severe respiratory distress who sounded like a washing machine. I gave Lasix. She turned out to have pneumonia. D’oh!
When I was a newer medic in the last 1990’s, one year I gave Lasix 21 times. If I thought I heard rales, I gave Lasix. I was told by another paramedic (be careful of your infomation sources) that Lasix was basically harmless. How many of those patients had pneumonia or sepsis? At least 40% is probably a close starting guess. This past year I didn’t give Lasix at all.
Several years back, we added the following caution to our regional protocols:
CHF vs. Pneumonia: If the clinical impression is unclear and transport time is not prolonged, consider using Nitroglycerin and withholding Lasix or Bumex or contact medical control.
Yet people continue to give Lasix to patients who are not in CHF. I think it stems from our natural incliniation to want to do something to help, particuarly if the patient’s respiratory distress is severe.
With CPAP and Nitro now the hallmarks of CHF treatment, I think it is clearly better to deny Lasix to someone who might have CHF than give it to someone with pneumonia or sepsis.
That seems to be the clear direction EMS is headed in. Check out this article from JEMS.
From our June 2009Regional Guidelines:
Class: Loop diuretic
Action: Blocks active reabsorption of chloride in the kidney, results in diuresis.
Mild venodilation results in decreased preload
Indication: Pulmonary edema
Children under 12 yrs
Pregnancy, caution with allergy to sulfa drugs but rarely cross reacts
Precaution: Lasix bolus should be given over 1 minute
Lung sounds should be noted before and after administration of Lasix
Patients already taking diuretics may require a high dosage
Side effect: Dehydration
Decreased circulating plasma volume
Decreased cardiac output
Loss of electrolytes K+ and Mg++
Dose: 0.5 – 1.0 mg/kg (usual dose 40 mg), or double patients usual daily dose up to 200 mg IV
Route: IV push – slow