Lasix

elephant

Lasix – Number 33 out of 33 on my Essential Drug List. (Note: Only 8 of the 33 will be ultimately deemed essential.)

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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.

Respectively
Patient X.

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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.

Evaluation of prehospital use of furosemide in patients with respiratory distress.

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.

Meds Under Scrutiny

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From our June 2009Regional Guidelines:

Furosemide (Lasix)

Class: Loop diuretic

Action: Blocks active reabsorption of chloride in the kidney, results in diuresis.
Mild venodilation results in decreased preload
Indication: Pulmonary edema

Contraindication:
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++
Transient hypotension

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

9 Comments

  • CBEMT says:

    The first time I ever gave 40mg of Lasix, I was wrong.

    So was the ER doctor who gave another 80mg immediately on our arrival.

  • medicscribe says:

    ED doctors make this mistake quite often as well. I have seen them order lasix from the doorway of a room. No history taking or asculattion of lungs much less a chest X-ray or BNP. I have also seen the errors in chart reviews.

    There are really two issues with lasix. 1, the common misdiagnosis, and 2, the growing arguement that even if properly diagnosed, Lasix, may not be the best drug for the patient in CHF. It might help them in the short-term, but can lead to more longer term problems. In other words, they do better in the ED, but worse in the ICU for having gotten Lasix.

  • I’ll echo CBEMT’s comments. It’s quite often inappropriately given in the ED as well.

    For my money, I think we’d do just as well or better with more liberal dosing of Nitro, and CPAP.

  • CBEMT says:

    I have seen them order lasix from the doorway of a room.

    That’s exactly what he did. I cleared the call patting myself on the back for my great diagnosis that had been confirmed so easily (I was a rookie ALS provider at the time).

    Talk to the same doctor a few days later, “Yeah, turns out it was pneumonia. He’s in the ICU now.” Oops.

  • Paramedic Pete says:

    I totally agree with the points raised. I know for a fact I have given Frusemide inappropriately. One of the reasons was that when the drug was first protocoled for us, it didn’t come with any training material. Way to go medical director, give paramedics a new drug and hope somehow they will just guess who the correct patients are. As you can imagine things really didn’t go that well.
    My only concern with ditching Frusemide is the patient who is crashing in front of you. The one who is catergorically in Acute Pulmonary Oedema and who you have to try and halt the dramatic deterioration. It was for these cases that I think Frusemide was protocolled in the first place. Maybe if it is limited to just patients obviously in extremis, then most of the problems would be hopefully negated. I just would hate to see a tool taken away which might tip the balance for a really sick patient.
    If it is taken away though, can we make sure we are given greater scope for other drugs we already carry, such as GTN infusions. Fulminating APO patients can really test any pre-hospital provider. I wouldn’t like to see poorer outcomes for these patients due to lack of training/ QI. Just a few thoughts.

  • Problem is, Pete, giving Lasix in the field for that patient in extremis, you’re still not going to see the effects for another 20-30 minutes.

    Lasix, when pushed fast, substantially reduces preload, which presumably would be beneficial for the patient with fulminating pulmonary edema. But when you push Lasix fast, you run significant risk of causing hearing damage.

    When I worked in rural EMS, where 30+ minute transports were commonplace, I gave a lot more Lasix than I do now in the city. Then again, we didn’t have CPAP or liberal Nitro dosing back then, either.

  • totwtytr says:

    We use less Lasix, and less frequently, than we used to. Time was when 100mg was not an uncommon dose. We gave it the other night, but in the end I’m convinced that it was more likely to be pneumonia than CHF. Still, the patient got some relief from the NTG, so only a CXR will tell for sure. More and more I prefer to take the conservative approach.

  • medicscribe says:

    Thanks for all the great comments,

    Peter

  • Paramedic Pete says:

    Ambulance Driver> I think CPAP and GTN are absolutely the preferred treatment options. I think some systems can take a while to change over to better alternatives due to inertia, cost, etc., even when there is sound comprhensive evidence to support the change. Frusemide has potentialy many problems, especially for patients with borderline renal function, let alone the miss administration. The point about frusemide used cautiously in a small subset of patients can buy you time and maybe stop an unneccessary intubation. We cover suburban, urban and country areas so the transport times can vary quite dramatically. I persinally have seen patients turn around from fulmonating Pulmonary Oedema to being able to talk to us. Sure this happened due to a combination of therapy including PEEP, but I’m sure Frusimide played a part. I guess because I’ve been around a while, I have seen so many changes which don’t seem to be supported by a breadth of good evidence just the opinion of a new medical director. When we do have good evidence and results, bring on the change but until then lets not remove things from patients who might make it to the ED because of them. Take care, Pete.

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Peter Canning

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