meerkat111

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I read somewhere take the total you are planning on giving for the day and run it over 4 hrs. How do you guys do this?
 

Nephro critical care

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Oh I try to make it as simple as possible. I would try a lasix gtt on someone who is not responding to lasix 80 mg BID. Or sometimes if I am being lazy and there is someone who I am sure is volume overloaded and I don't want to make an assessment every 8 hrs about his UOP then I would do a lasix gtt. I typically will give them a 60 mg bolus and then place on gtt at 5 mg/hr. Check later in the day and if UOP is not adequate increase it to 10 mg / hr , max is 15/20 mg/hr . Few caveats are you can't do this on a lasix naive person otherwise you'll kill them. This is typically for a CHFer +/ ve CKD or a septic shock recovered ICU pt who is 10-20 L positive. You will leave on gtt on for 24 -48 hrs until you have your goal negative. BMP, mag, pros need to be monitored q8-12 hrs. Max gtt can be left on for is 72 hrs after which ototoxicity risk is higher.
It works like a charm though. One of my nephrology professors taught me that with a gtt , after about 12 hrs of the gtt the Na-K-2Cl receptors get totally saturated and if the pt is going to pee , he will.
 
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TimesNewRoman

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Maybe I misunderstood your post. Lasix gtt is not given one bolus at a time it's a 60,80 or 120 mg bolus followed by gtt stating at 5mg/hr and titrating up to 10 -15 mg / hr.
I was making a joke that I don't personally use lasix drips.

I can use them, but I usually just bolus because there is more data for that.
 

Nephro critical care

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I was making a joke that I don't personally use lasix drips.

I can use them, but I usually just bolus because there is more data for that.
They do work though. Common circumstance that often happens is that there is a guy I have being diuresing with bolus doses and I intend to get 3 L negative. I have him a 60 mg or 80 bolus and then intend to come around to 1 or 2 pm and give another bolus if UOP isn't adequate. But then 4-5 admits pop up its a procedureorama and I am busy till 9 pm. I had no NP so if I didn't come back no one else would look at UOP. The nurse was lazy and never keeps an eye on the pt to remind me. Now it's 10 pm I am dead tired and I come back and pt is still 1 L positive for the day with all his various gtts/IV meds. Now even with another bolus he will still remain positive for the day.
If I had done a lasix gtt he would have been guaranteed -ve at 9 pm and lasix gtts don't drop your BP either unlike large bolus doses which might cause venodilation and drop preload. So as long as I checked lutes and put electrolyte replacements you can get away with a gtt with impunity.
 

Nephro critical care

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or you could just schedule the second bolus for 2 pm and go do your admits? problem solved
Yes that's true . But if you have been doing the boluses for 2 or 3 days i.e you were doing 40 mg BID on day 1 , 60 BID on day 2 and today you are thinking about 80 mg BID or TID maybe better to do a gtt and get a guaranteed negative. I also believe gtts cause less hypotension than intermittent boluses.
 
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jdh71

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Give 40. Start the drip at 40 per hour and nursung can titration the drip rate by 10 per hour up or down to a desired UOP per hour. Easy.

What I like about drips even though I don't use them regularly is that I can't take back a bolus. What I like about lasix is that it's not poison.
 

end stage fibro

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Usual scenario:

Me: Hm this guy is wet, maybe I'll increase Lasix boluses
cardio: Hey this guy is wet. I'm gonna start on bumex gtt
Me: er...ok. Doesn't that have worse renal outcomes?
cardio: The kidneys exist to purify blood for the pump. That's why there dialysis and no heartalysis.
Few days pass, now delta of serum Cr.>> pt weight loss. get renal consult
renal: why did you start drip? Don't you know...the wetter the better. Just give boluses.
leaves service...comes back in 5 days. pt ready for discharge. oof
 

TimesNewRoman

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Give 40. Start the drip at 40 per hour and nursung can titration the drip rate by 10 per hour up or down to a desired UOP per hour. Easy.

What I like about drips even though I don't use them regularly is that I can't take back a bolus. What I like about lasix is that it's not poison.
Ummmm....you'll start a lasix drip at 40 and titrate up!?!? You'll give someone over a gram of lasix???
 

jdh71

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Both my residency institution and fellowship institution capped at 20.....40 seems excessive.
If the patient's beans need it they need it. You titrate up or down to urine output. Where is your horrified reaction here based? Dogma from training?
 

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TimesNewRoman

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If the patient's beans need it they need it. You titrate up or down to urine output. Where is your horrified reaction here based? Dogma from training?
1) Hearing loss

2) If someone needs a gram of lasix, I don't know why you wouldn't just put in a line and spin them.
 

jdh71

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1) Hearing loss

2) If someone needs a gram of lasix, I don't know why you wouldn't just put in a line and spin them.
Hearing loss doesn't start until around 300mg per hour.

If they are making urine, they are making urine. First do no harm.
 
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Nephro critical care

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Hearing loss doesn't start until around 300mg per hour.

If they are making urine, they are making urine. First do no harm.
I am a big proponent of lasix gtt as compared to boluses but max I go is 20 mg/hr. By then you aren't getting the same bang for your buck and I would worry about ototoxicty especially as ICU hearing tests are kind of unreliable. Must people will pee on lasix 20/hr or bumex 1/hr if they have a creatinine < 3.5. I will be thinking about SCUF at that point.
I used to do a lot of CRRT and SLED but our nephrologists got territorial. I will put the lines in for them and while they control the machine they will let me run the UF rate.
 

jdh71

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I am a big proponent of lasix gtt as compared to boluses but max I go is 20 mg/hr. By then you aren't getting the same bang for your buck and I would worry about ototoxicty especially as ICU hearing tests are kind of unreliable. Must people will pee on lasix 20/hr or bumex 1/hr if they have a creatinine < 3.5. I will be thinking about SCUF at that point.
I used to do a lot of CRRT and SLED but our nephrologists got territorial. I will put the lines in for them and while they control the machine they will let me run the UF rate.
If they stop peeing, sure, but if it's going it's going. If it's needed it's needed.

I was in the middle of a trauma surgery as a medical student, guy was shot up then hit by a car as he stumbled out into the street. Amazing he was still alive (the benefits of being young and male), and during the ex-lap, the surgeon ligated the common femoral vessels. Because he had to, to save the guy. When asked how he felt about such a drastic step, his response was, "I didn't shoot the guy and run him over . . . I merely did what was necessary to save his life". That impacted me.

One of the biggest problems for many medical critical care docs is a pedantic holding to certains dogmas, and an inability to make decisions that patients occasionally need for us to make that are thinking around corners or outside of boxes. There aren't any RTCs worth a damn in our line or work that aren't so noisy as to be basically unusable in any practical fashion for our every day practice. Any doc who can be replaced by an algorithm should be. Is pushing the limits for patients reckless or what they need? Is holding to dogma and an unwillingness to go certain places safe or cowardly? It's kind of muddy, yeah?

When it comes to Lasix drips, I start high and titrate to a urine out put (which often means titrating down - it's not merely an upward suicide pact). If they are making urine and they need a high dose as long as no obvious adverse effects are present I stay the course. Am I reckless or am I bold for my patients? If it stops working, they get some machine style help. I didn't give them the problem that required the Lasix drip . . . but I am going to try and help. Even if that help makes some of you squeamish.
 
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Instatewaiter

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I have used 40mg/h once. I have used 30mg/h many times. Usually when I get north of 20mg/h I am adding a thiazide (5 or 10mg metolazone, 50- 200 mg HCTZ or 1000 of diuril). Anectodally I have found if they're not peeing with a thiazide and 30mg/h of lasix, they're probably not going to pee with diuretics.

Instead of hitting them with massive guns from the outset, I usually estimate their need by their renal function and home dose of diuretics (I do HF/Transplant so everyone is on diuretics at home) and uptitrate, but to each their own.

Apparently you have to be a ****-tons of lasix to cause ototoxicity ~4mg/min (like a drip at 240/h) but I don't really want to find out. Bumex causes less ototoxicity when normalized by potency but most places I have been prefer lasix probably d/t cost.
 
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Instatewaiter

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Usual scenario:

Me: Hm this guy is wet, maybe I'll increase Lasix boluses
cardio: Hey this guy is wet. I'm gonna start on bumex gtt
Me: er...ok. Doesn't that have worse renal outcomes?
cardio: The kidneys exist to purify blood for the pump. That's why there dialysis and no heartalysis.
Few days pass, now delta of serum Cr.>> pt weight loss. get renal consult
renal: why did you start drip? Don't you know...the wetter the better. Just give boluses.
leaves service...comes back in 5 days. pt ready for discharge. oof
I might have to use that... about the heartalysis....

Also, no difference in renal outcomes with bolus vs drip (DOSE trial, NEJM... don 't quote me that garbage study from CC journal with <80 patients)

Personally, I don't care what the nephrologist has to say about filling pressures. I can't tell you how many times they have told me to give fluids because the guy is dry (FYI I have a ****ing swan in their neck and have full knowledge of their filling pressures- note a wedge of 30 is the opposite of dry). Those of you who are still in training will eventually realize that a good nephrologist who not only finds rare causes of renal failure but also will just orders dialysis when you want it is worth their weight in gold.
 
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go lakers

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Please see page 6 of appendix from CARRESS-HF trial for a suggestion on initiation and uptitration parameters for a lasix drip:
MMS: Error
 

jdh71

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I might have to use that... about the heartalysis....

Also, no difference in renal outcomes with bolus vs drip (DOSE trial, NEJM... don 't quote me that garbage study from CC journal with <80 patients)

Personally, I don't care what the nephrologist has to say about filling pressures. I can't tell you how many times they have told me to give fluids because the guy is dry (FYI I have a ****ing swan in their neck and have full knowledge of their filling pressures- note a wedge of 30 is the opposite of dry). Those of you who are still in training will eventually realize that a good nephrologist who not only finds rare causes of renal failure but also will just orders dialysis when you want it is worth their weight in gold.
It's just ATN and you suck.

Thank you for this consult.
 
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