Inappropriate LASIX use in the field???

[Ace844]

Hello Everyone,

I ran across this study and article and thought you may be interested....

Hope this Helps,

ACE844

(”Prehospital Emergency Care

Publisher: Taylor & Francis Health Sciences @ part of the Taylor & Francis Group

Issue: Volume 10, Number 2 / April-June 2006

Pages: 194 - 197

URL: Linking Options

DOI: 10.1080/10903120500541282

Evaluation of Prehospital Use of Furosemide in Patients with Respiratory Distress

Jason Jaronik A1, Paul Mikkelson A1, William Fales A1, A2, David T. Overton A1 A1 Department of Emergency Medicine, Michigan State University Kalamazoo Center for Medical StudiesA2 Kalamazoo County Medical Control Authority, Kalamazoo, Michigan”)

Abstract: Objective. To evaluate the appropriateness of prehospital use of furosemide. Methods. All patients over 18 years old receiving prehopsital furosemide were retrospectively identified, and cases were matched to subsequent hospital records. Data collected included ED and hospital primary and secondary diagnoses, brain-type natriuretic peptide (BNP) levels and final disposition. Furosemide was considered appropriate when the primary or secondary ED or hospital diagnoses included congestive heart failure (CHF) or pulmonary edema, or the BNP was > 400. Furosemide was considered inappropriate when none of the diagnoses included CHF, when the BNP was < 200, or when an order for IV fluid hydration was given. Furosemide was considered potentially harmful when the diagnoses included sepsis, dehydration or pneumonia, without a diagnosis of CHF or BNP > 400. Results. Of the 144 included patients, a primary or secondary diagnosis of CHF was reported in 42% and 17% patients, respectively. The initial BNP was > 400 in 44% of the 120 patients in which this lab test was obtained. Sixty patients (42%) did not receive a diagnosis of CHF, 30 (25%) patients had a BNP < 200, and 33 (23%) had an order for IV fluid hydration. A diagnosis of sepsis, dehydration or pneumonia without a diagnosis of CHF or a BNP > 400 occurred in 17% of patients. Seven of the 9 deaths did not receive a diagnosis of CHF. Furosemide was considered appropriate in 58%, inappropriate in 42% and potentially harmful in 17% of patients. Conclusions. In this EMS system, prehospital furosemide was frequently administered to patients in whom its use was considered inappropriate, and not uncommonly to patients when it was considered potentially harmful. EMS systems should reconsider the appropriateness of prehospital diuretic use.

Summary and Comment

Inappropriate Use of Diuretics in the Prehospital Setting Although there is no proven link between early diuretic administration and improved outcome in patients with congestive heart failure (CHF), diuretic use is common in the prehospital setting. Little is known about the appropriateness or benefits of this practice. Using a database from a single emergency medical service, investigators identified all instances of prehospital furosemide use during a 12-month period and reviewed patients’ emergency department and hospital charts. Furosemide use was deemed appropriate when the primary or secondary ED or hospital diagnosis included CHF or pulmonary edema, or when the brain-type natriuretic peptide (BNP) level was >400 pg/mL. Use was deemed inappropriate when the diagnoses did not include CHF or pulmonary edema, the BNP level was <200 pg/mL, or when intravenous fluids were given in the ED. Furosemide was considered potentially harmful in patients with a diagnosis of sepsis, dehydration, or pneumonia who did not have a diagnosis of CHF or pulmonary edema or a BNP level >400 pg/mL. Of 146 patients who received furosemide in the prehospital setting, 144 had complete records available. CHF was diagnosed in 58%. Intravenous fluids were administered upon hospital arrival in 23%. Furosemide use was considered appropriate in 58%, inappropriate in 42%, and potentially harmful in 17%. Nine of the 146 patients died. Seven of those who died did not have a diagnosis of CHF. Comment: Compared with other medications for CHF, such as nitrates and morphine, diuretics work very slowly, so the likelihood of benefit from administration in the prehospital setting is low. This study shows that, at least in one EMS system, prehospital use of diuretics is as likely to be inappropriate as appropriate and might even be harmful in many cases. It is unlikely that these findings are limited to a single system or to use of diuretics for CHF. A similar evaluation of the use of other medications in the prehospital setting would be worthwhile. — Daniel J. Pallin, MD, MPH Published in Journal Watch Emergency Medicine June 13, 2006 Source Jaronik J et al. Evaluation of prehospital use of furosemide in patients with respiratory distress. Prehosp Emerg Care 2006 Apr/Jun; 10:194-7.

[Ace844]

(Diuretic Use @ Progressive Heart Failure, and Death in Patients in the DIG Study

Michael Domanski, MD1, Xin Tian, PhD2, Mark Haigney, MD3, Bertram Pitt, MD4

Received 20 October 2005; received in revised form 23 February 2006; accepted 15 March 2006

Bethesda, Maryland; Ann Arbor, Michigan)

Abstract

Background

Nonpotassium-sparing diuretics (NPSDs), have been associated with increased sudden cardiac death (SCD) and progressive heart failure (HF) death in HF patients.

Methods and Results

In 6797 Digitalis Investigation Group study patients, risk ratios were calculated for death, cardiovascular death (CVD), death from worsening HF, SCD, and HF hospitalization among those taking a potassium-sparing (PSD), NPSD, or no diuretic. Compared with not taking diuretic, risk of death (relative risk [RR] 1.36, 95% confidence interval [CI] 1.17–1.59, P < .0001), CVD (RR = 1.38, 95% CI 1.17–1.63, P = .0001), progressive HF death (RR = 1.41, 95% CI 1.06–1.89, P = .02), SCD (RR = 1.67, 95% CI 1.23–2.27, P = .001), and HF hospitalization (RR = 1.68, 95% CI 1.41–1.99, P < .0001) were increased with NPSD. There was no significant difference in any end point for patients taking only PSD compared to no diuretic. PSD only subjects were less likely than NPSD subjects to be hospitalized for HF (RR = 0.71, 95% CI 0.52–0.96, P = .02).

Conclusion

NPSDs are associated with increased risk of death, CVD, progressive HF death, SCD, and HF hospitalization. A randomized trial is needed to assess the role of NPSDs versus PSDs in HF patients.

[buckeyedoc]

Ironic that you brought this up. We were dispatched for resp. distress. We get there and the pt.'s O2 sat was 80% on 15L. You can tell he's having serious difficulty breathing, +3 pitting edema, lungs were wet and had crappy central skin turgor. I gave him an Albuterol/Atrovent breathing tx. and his sat came up to 86-88%. He said that that really helped him. His highest B/P was 102, so I didn't really want to give any NTG. The only access he had was a PICC line and we can't access them except in a code. When we got to the hospital, the nurse was upset that I didn't give him Lasix. I explained to her why I didn't....the possibility for hypovlemic shock. She was torqued that I didn't give any. I explained to the doctor why I didn't give NTG or Lasix and he was fine with it. I don't know whether the nurse was pissed because of the pt. not getting NTG/Lasix or the fact that a medic showed her up. Normally, the nurses there at that ER is wonderful, but that nurse was an agency nurse.

[TechMedic05]

Just out of curiosity...And the fact that my brain is not working adequately tonight- Are there any potential reasons why both lasix and hydration would be warranted?

I can't speak to defend Paramedics I don't know, calls I wasn't on, but the way that they automatically assume that any patient who received a fluid bolus was immediately 'Not in CHF' - assuming that Lasix was inappropriate.

Just thinking out loud.

Edit: one thing I can think of, although extreme and rare- perhaps a patient with hypoalbuminemia - Who could potentially present sick, with CHF/pulmonary edema signs [lack of oncotic pressure], and require fluid later for a general volume deficiency from the hypoalbuminemia itself.

Again, I'm just thinking out loud here. Who knows, maybe a decent discussion will follow :-D

[chbare]

TechMedic05, I have given both fluids and lasix to people in rhabdo and to people who present with conditions that may cause rhabdo. (trauma, crush injuries, etc) We do not want those kidneys shutting down. I can think of a few other situations where fluids and diuretics may be given.

Take care,

chbare.

[TechMedic05]

TechMedic05, I have given both fluids and lasix to people in rhabdo and to people who present with conditions that may cause rhabdo. (trauma, crush injuries, etc) We do not want those kidneys shutting down. I can think of a few other situations where fluids and diuretics may be given.

Take care,

chbare.

Thank you! I thought of that this morning after I woke up. Brain wasn't quite fuly operational last night.

So, in a situation where both fluid and lasix are not inappropriate treatments together, there's no consideration in the study. As in, it's only black and white.

Just food for thought.

[Ridryder 911]

Now, re-read that study! It is a horribly flawed and very tainted study. This is the reason medics and physicians really need to learn more about studies. If you will notice that all comparisons were based upon BnP levels. Great.. hell, even a 5'th grade could figure that one out. Hell, yes it's easy to say hold the lasix when you have conclussive findings such as CXR and labs!

Let's do a real comparison of assessment skills for a study. Those of paramedics, physicians, internist, cardiologist and then see what is ordered or not before labs and x-ray. I have seen physician order lasix way before HBnP ever was drawn and be wrong, and a another concern is that HBnP takes a while for it to process. Again, treat the patient accordingly, BnP is a wonderful tool, that especially gives a precursor of CHF.

I agree, use of CPAP, Nitrates should used more often, but administration of Lasix can be of wise choice not just as a diuretic, but anti-hypertension use as well.

R/r 911

[AZCEP]

Thank you Rid!

Finally, someone remembering that the first effect to be seen from Lasix is vasodilation. Reduce preload, give the fluid in the lungs someplace to go, improve the situation.

The chest film isn't going to be much help in telling pulmonary edema from pneumonia or effusion, and God help you if you can't breathe and you are waiting for the lab to tell you what treatment you should receive.

Also consider, Dopamine and Lasix are used together to improve hemodynamics fairly commonly. Using fluid boluses with Lasix can also help this situation, not as dramatically as with Dopamine, but the effect would be along the same lines.

As an aside, there must be a dozen or so separate threads on CHF at the same time. Is this really this big of a problem?

[Ace844]

Now, re-read that study! It is a horribly flawed and very tainted study. This is the reason medics and physicians really need to learn more about studies. If you will notice that all comparisons were based upon BnP levels. Great.. hell, even a 5'th grade could figure that one out. Hell, yes it's easy to say hold the lasix when you have conclussive findings such as CXR and labs!

Let's do a real comparison of assessment skills for a study. Those of paramedics, physicians, internist, cardiologist and then see what is ordered or not before labs and x-ray. I have seen physician order lasix way before HBnP ever was drawn and be wrong, and a another concern is that HBnP takes a while for it to process. Again, treat the patient accordingly, BnP is a wonderful tool, that especially gives a precursor of CHF.

I agree, use of CPAP, Nitrates should used more often, but administration of Lasix can be of wise choice not just as a diuretic, but anti-hypertension use as well.

R/r 911

"Rid& Everyone,"

Your statement is among one of the resons I posted this study, and I also intended it to be an example of how a single, and potentially flawed study should not be used to make 'knee jerk' reactions about a treatment or intervention... I'm going to include a quote from the above post which highlights how soem clinicians 'don't say much' when commenting on a study which is not necessarily conclusive::

This study shows that, at least in one EMS system, prehospital use of diuretics is as likely to be inappropriate as appropriate and might even be harmful in many cases. It is unlikely that these findings are limited to a single system or to use of diuretics for CHF. A similar evaluation of the use of other medications in the prehospital setting would be worthwhile.

Food for thought, now let's continue with our discussion, perhaps you guys have some other 'opinions' on this as well...?

ACE844

[emt322632]

This is actually more of a question than a comment, I'm new to the ALS game, only had my cert a month or so.

In question to Buckeyedoc's post about giving Albuterol/Atrovent to a pulmonary edema patient, I was taught by my preceptor that this was a huge no no. I understand that Lasix and NTG can cause hypotension, and with a BP of 102 I'd probably consult medical control before initiating treatment. My question is, wouldn't an albuterol/atrovent treatment potentially exacerbate things later?

This is what I was taught, although I was never exactly told why it would do so...Something to do with the fact that it only dilates the bronchioles and such and does nothing for actually removing the fluid from the lungs...

Just curious...someone help:-)