#7652 - 11/13/05 10:45 AM
Re: LASIX Dose
[Re: Chris Marks]
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Corey Ricketson
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Chris,
I will look for literature on it. This is exactly what the Clinical Advancement Team was formed for. If I can find some GOOD supporting evidence for this, we will absolutely bring it up.
Corey
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#7653 - 11/13/05 12:28 PM
Re: LASIX Dose
[Re: Corey Ricketson]
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Corey Ricketson
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I looked in PUBMED which is where all the research studies are published. I am finding nothing there. The only thing I find is on chronic lasix doses, not emergent patients. You should try to get more info on this study so we can read it. The post below this one about treating CHF suggests relying on nitrates and ace inhibitors as the mainstay of treatment and less on lasix. The suggestion also opposes the routine use of morphine in CHF. This is one doctor's recommendation, however, and is not backed up by any conclusive studies.
We, as an organization, have to be careful about looking at studies as gospel without diving into the methods used to collect data, how many participants were in the study and the margin of error and confidence intervals involved with the studies. This is why I want to be able to look at the study you mention in it's entirety. You can be sure that if we find a study with good conclusive evidence that we are doing harm to a patient with our treatments, we will fight to get those treatments removed and other treaments to replace them.
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#7654 - 11/13/05 09:31 PM
Re: LASIX Dose
[Re: Chris Marks]
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Jonathan Mudge
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Chris,
St.Davids has done some recent studies on CHF. I think a lot of what you're hearing is based on their work.....not some of the new literature. I could be wrong. As Corey said the direction treatment is heading in is to put lasix way down on the treatment plan. Hit 'em hard with Nitrates...get the vaso-dilatory effects going on and reperfusion of the coronary arteries. Morphine..I've only heard of St. Davids not wanting to use it. Morphine can still be beneficial because of the histamine release...causes more dilatory effects....plus some benefits with anxiety (maybe). The thing about Lasix is that you're going to stress the kidneys....period. About 25% of cardiac output goes to the kidneys. When they start getting hammered they release renin...converts angiotensin 1 to 2...causes profound vasoconstriction..tachycardia...plus aldosterone effects. You can see where this is going. This is why they are suggesting ACE inhibbitors as well. All these things can start getting the pressure gradients back in line and the heart can do its job. Lasix is still there...just in different scenarios. Obviously positive pressure ventilation is ideal...bag..cpap..tube..whatever is needed. Personally I've been going this treatment route lately and have had good results. It has also made some Doc's happy too. Anyway....this is what I know about it. Hope this helps.
Mudge
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#7655 - 11/13/05 10:32 PM
Re: LASIX Dose
[Re: Jonathan Mudge]
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Corey Ricketson
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Jonathan,
Interesting discussion regarding the histamine release. I actually hadn't thought about the histamine release as a positive effect of Morphine but I guess it could be. Here is an exerpt from the article I was referring to which actually suggests the contrary. I suppose it could be a double edged sword so we have to be careful not to give it too fast or too much of it.
"Although morphine is a common addition to the NTG regimen for preload reduction, there is very little evidence that it is effective in this regard, he said. In fact, there is significant evidence that it can cause respiratory and myocardial depression at high doses, Dr. Mattu said, and its histamine-related side effects such as rash, urticaria, nausea, and vomiting can actually increase catecholamine release, which worsens the problem."
Good post Jonathan.
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#7657 - 11/14/05 12:57 AM
Re: LASIX Dose
[Re: Chris Marks]
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Corey Ricketson
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Yes it would, and maybe the doctor could use a little re-education from ED if he is reading our medics the act for following the SOC's.
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#7658 - 11/14/05 04:54 AM
Re: LASIX Dose
[Re: Corey Ricketson]
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Jonathan Mudge
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Funny thing about Docs....
I was having a discussion with a Seton Doc about this very issue. He has been trying to incorporate some of these changes. He made the comment that some of his colleagues (at Seton) had absolutely no idea what he was talking about.
If I were the Medic...well... You can't yell at somebody for doing something "wrong" when they don't know it's "wrong." Caveat: It still may not be "wrong."
Give me a friggin break...
Yep....good discussion.
Mudge
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#7659 - 11/14/05 04:59 AM
Re: LASIX Dose
[Re: Corey Ricketson]
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Jonathan Mudge
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The subject of Morphine is probably like so many others in medicine. 1 big guessing game.
Thanks for the compliment Corey.
Mudge
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