Furosemide by karishma

INTRODUCTION OF FUROSEMIDE
CLINICAL DATA
CHEMISTRY OF DRUG (INCLUDING DRUG PROPERTIES)
DRUG DATABASES (AVAILABILITY,STORAGE,DOSAGE,ROUTE PREFERENCE)
PHARMACOKINETICS (SITE OF ACTION,TIME/ACTION PROFILE)
MECHANISM OF ACTION
ACTIONS
DESIRED EFFECT
INDICATIONS
THERAPEUTIC USES
CONTRAINDICATIONS
PRECAUTIONS
ADVERSE EFFECTS/SIDE EFFECTS
WARNINGS INCLUDING DOSE ADJUSTMENT IN SPECIAL POPULATION
DRUG INTERACTIONS
TOXICOLOGY & IT’S MANAGEMENT
NURSING CONSIDERATIONS
;RESPONSIBILITIES;ASSESSMENT;POTENTIAL DIAGNOSIS; IMPLEMENTATIONS;EVALUATIONS DURING FUROSIDE ADMINISTRATION
PATIENT/FAMILY TEACHING
SPECIAL CALCULATIONS
CONCLUSION OF FUROSEMIDE
REFERENCES OF FUROSEMIDE

1. FUROSEMIDE PRESENTED BY : KARISHMA SINHA

2. INTRODUCTION CLINICAL DATA CHEMISTRY OF DRUG (INCLUDING DRUG PROPERTIES) DRUG DATABASES (AVAILABILITY,STORAGE,DOSAGE,ROUTE PREFERENCE) PHARMACOKINETICS (SITE OF ACTION,TIME/ACTION PROFILE) MECHANISM OF ACTION ACTIONS DESIRED EFFECT INDICATIONS THERAPEUTIC USES CONTRAINDICATIONS PRECAUTIONS ADVERSE EFFECTS/SIDE EFFECTS WARNINGS INCLUDING DOSE ADJUSTMENT IN SPECIAL POPULATION DRUG INTERACTIONS TOXICOLOGY & IT’S MANAGEMENT NURSING CONSIDERATIONS;RESPONSIBILITIES;ASSESSMENT;POTENTIAL DIAGNOSIS; IMPLEMENTATIONS;EVALUATIONS PATIENT/FAMILY TEACHING SPECIAL CALCULATIONS CONCLUSION LEARNING OBJECTIVES :

3. WHAT ARE DIURETICS? A diuretic is any substance that promotes  diuresis , the increased production of  urine by increasing the excretion of  water  from the body, through the  kidneys . INTRODUCTION:

4. TYPES OF DIURETICS :

5. What are High ceiling/loop diuretics? A type of diuretic that acts at the ascending limb of the  loop of Henle  in the  kidney . loop diuretics are more effective in patients with impaired kidney function . Loop diuretics, such as  furosemide , inhibit the body's ability to reabsorb  sodium  at the ascending loop in the  nephron , which leads to an excretion of water in the urine, whereas water normally follows sodium back into the extracellular fluid. Examples of loop diuretics: Furosemide Bumetanide Ethacrynic acid Torasemide

6. A type of loop/high ceiling diuretic which acts on Loop of Henle by increasing excretion of sodium & chloride or Given in a tablet form directly to prevent reabsorption of sodium and potassium mainly from the loop of Henle. May cause a substantial diuresis – up to 20% of the filtered load of  NaCl  (salt) and water. FUROSEMIDE:

7. Available brands in India: S.no. Brand Manufacturer Presentation ROA Strength Retail price 1. Diucontin-K  Modi Mundi Diucontin-K TAB Oral Tab:20mg, 40mg 272.50, 527.50 2. Fru   Ind - Swift Fru AMP IV/IM Amp: 20mg/mL 2.83 3. Frusemene   GSK Frusemene TAB Oral Tab:20 mg,40 mg 19.99, 24.70 4. Frusenex   Geno Frusenex TAB Oral Tab:40mg, 100mg 3.89, 4.25 5. Frusim Chandra BhagatPharma Frusim AMP IM/IV Amp: 10mg/2mL 29.50 6. Frusix Inj   Cipla Frusix Inj INJ Inj:20mg x 1mL x 2mL 2.69 7. Furoped Samarth Furoped SOLN IV/IM Inj: 10mg x 1mL 90.00 8. Lasix Sanofi Aventis Lasix INJ, Lasix TAB IV/ IM,Oral Inj: 10mg x 1mL, 10mg x 1mL Tab : 40mg 3.00, 6.74, 105.25 9. Lasix High Dose  Sanofi Aventis Lasix High Dose INJ,Lasix High Dose TAB IV/ IM,Oral Inj: 250mg x 25mL Tab:500mg 38.33, 28.31 10. Salinex IDPL Salinex TAB Oral Tab: 40mg 2.69 11. Tebemid Neon Labs Tebemid TAB Oral Tab: 40mg 25.95 12. Urix Intas Urix INJ IV/IM Inj:10mg 2.95

8. DRUG NAME: Generic Name:Furosemide Trade Name:Lasix,others CLASSIFICATION: Pharmacologic:Loop diuretic Therapeutic:Loop diuretic(Water pills) PREGNANCY CATEGORY RISK: C ROUTES OF ADMINISTRATION: By mouth Intravenous Intramuscular CLINICAL DATA:

9. This compound belongs to the class of organic compounds known as aminobenzenesulfonamides . T hese are organic compounds containing a benzenesulfonamide moiety with an amine group attached to the benzene ring. Organoleptic properties: Color : White Taste: Metallic taste Shape: Round, elliptical or oval Physical properties: Melting Point: 206°C Solubility: It is also soluble in methanol (50 mg/ml), with heat as needed. It is slightly soluble in ethanol, soluble in methanol, DMSO, and alkali hydroxides. Furosemide is practically insoluble in water. CHEMISTRY OF DRUG:

10. Basic Properties: Cheap, effective and most efficacious as compared to other classes of diuretics in mobilizing Na and Cl from body. Most commonly used diuretic drug Efficacy proven in clinical trials. Lesser side effects as compared to the ethacrynic acid but Bumetanide is more potent and its use is increasing.

11. Chemical and physical data of furosemide: Formula C 12 H 11 ClN 2 O 5 S Molar mass 330.74 g·mol −1 Ball-and-stick model of the furosemide molecule :

12. Structural formula of furosemide

13. AVAILIABILITY: Tablets:20,40,80mg Oral solution:10mg/ml,40mg/ml Injection:10mg/ml STORAGE: Oral : Solution or Tablets:Tight , light resistant containers at 15-30°C. Store oral solution at room temperature. Protect from direct light. Parenteral: Injection:15-30°C, protect from light & discard unused portion. DRUG DATABASES:

14. Neonatal dose: Initial dose: 1mg/kg given PO or IV slow push over 1-2 minutes; maximum dose: 6 mg/kg PO or 2 mg/kg IV. Recommended dosing interval: Premature infant: q 24 hours Full term infant: q12 hours Child >1mo : (PO)-2mg/kg as a single dose, may be increased by 1-2mg/kg every 6-8 hrs and should not be more than 6mg/kg of body weight/day, Consider alternate day therapy for long-term use to minimize potential adverse effects. DOSAGE:

15. Adults : ( PO) 20-80mg/day as a single dose initially, may repeat in 6-8 hrs , may increase dose by 20-40mg every 6-8 hr until desired response. maint:40-120 mg/ d;max : 600 mg/d. IM/IV:20-40 mg over 1-2 min IV; repeat 20 mg in 2 h; max:4mg/min inf Dose for pregnant woman: 40mg tablet following breakfastx5days in a week In acute conditions=40-20mg daily(administered parenterally). Minimum dose:1mg/kg; Maximum dose:40mg(may increase dose in increments of 20mg in 2 hr )

16. Oral, IV: Edema associated with heart failure, cirrhosis, renal disease. IV : acute pulmonary edema . Oral : hypertension . IM: restricted to exceptional cases where neither oral nor intravenous administration is feasible. It must be noted that IM injection is not suitable for the treatment of acute conditions such as pulmonary edema . ROUTE PREFERENCE :

17. Molecular weight ( daltons ): 330.7 Bioavailability : 43-69% Bioavailability with end-stage renal disease 43 - 46% Protein binding: 91-99% Metabolism Liver & kidney glucuronidation (but this percentage may be greater in individuals with severe kidney failure). Onset of action: 30-60 min(PO), 5 min (IV). Elimination/ half-life: Upto 100 min or upto 2hr. Prolonged in congestive heart failure (mean 3.4 hrs ) Prolonged in severe kidney failure (4-6 hrs ) & anephric patients(1.5-9 hrs ). Excretion: Kidney 66%, bile duct 33%. % Excreted in feces (% of total dose) 7 - 9 % Excreted in bile (% of total dose) 6 - 9 % Excreted in urine (% of total dose) 60 - 90 % Excreted unchanged in urine (% of total dose) 53.1 - 58.8  PHARMACOKINETICS:

18. Volume of distribution (L/kg): 0.07 – 0.2 ( Volume of distribution may be higher in patients with cirrhosis or nephrotic syndrome). Distribution: Crosses placenta, enters breast milk. Absorption: 60-67% absorbed after oral administration ( in acute HF and in renal failure); also absorbed from IM sites. Time to peak concentration( hrs ): Intravenous administration 0.3 Oral solution 0.83 Oral tablet 1.45

19. SITE OF ACTION: Ascending limb of loop of henle

20. Route Onset Peak Duration PO 30-60min 1-2hr 6-8hr IM 10-3-min Unknown 4-8hr IV 5mi 30min 2hr TIME/ACTION PROFILE (diuretic effect):

21. Inhibits the luminal  Na-K-Cl cotransporter  in the  thick ascending limb of the  loop of Henle , by binding to the chloride transport channel, thus causing more sodium, chloride, and potassium to stay in the urine. Because of the large NaCl absorptive capacity of the loop of Henle, diuresis is not limited by development of acidosis, as it is with the carbonic anhydrase inhibitors. Mechanism of Action:

22. ACTIONS :

23. DESIRED EFFECTS: Has many therapeutic effects also…

24. For the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease, including the nephrotic syndrome. Also for the treatment of hypertension alone or in combination with other antihypertensive agents. . Duration: Diuresis effect persists 6-8 hrs following oral administration, while approximately 2 hrs following IV administrations INDICATIONS:

25. Drug of choice for the reduction of the acute pulmonary edema of heart failure. In acute pulmonary edema because of rapid onset of action particularly when given intravenously therefore this is used in emergency cases.(which calls for rapid diuresis) Hypocalcaemia treatment along with hydration. This is also useful for the treatment of hyperkalemia. THERAPEUTIC EFFECTS: Diuresis and subsequent mobilization of excess fluid (edema, pleural effusions). Decreased BP. THERAPEUTIC USES:

26. CONTRAINDICATIONS:

27. PRECAUTIONS: Use cautiously with: SLE Gout Diabetes mellitus

28. Use Cautiously in: Severe hepatic impairment (may precipitate hepatic coma; concurrent use with potassium-sparing diuretics may be necessary); Electrolyte depletion; Diabetes mellitus; Hypoproteinemia (↑ risk of ototoxicity); Severe renal impairment (↑ risk of ototoxicity) OB: Use during pregnancy only if potential maternal benefit justifies potential fetal risk Lactation:  Use while breastfeeding only if potential maternal benefit justifies potential risk to infant Pedi:   ↑ risk for renal calculi and patent ductus arteriosis in premature neonates; Geri:   Older adults may have ↑ risk of side effects, especially hypotension and electrolyte imbalance, at usual doses.

29. CV:  hypotension Derm :  ERYTHEMA MULTIFORME, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, photosensitivity, pruritus, rash, urticaria EENT:  hearing loss, tinnitus Endo:  hypercholesterolemia, hyperglycemia , hypertriglyceridemia, hyperuricemia F and E:  dehydration ,  hypocalcemia ,  hypochloremia ,  hypokalemia ,  hypomagnesemia ,  hyponatremia ,  hypovolemia ,  metabolic alkalosis GI:  anorexia, constipation, diarrhea , dry mouth, dyspepsia, ↑ liver enzymes, nausea, pancreatitis, vomiting GU:  ↑ BUN, excessive urination, nephrocalcinosis Hemat :  APLASTIC ANEMIA, AGRANULOCYTOSIS, hemolytic anemia , leukopenia, thrombocytopenia MS:  muscle cramps Neuro:  paresthesia , blurred vision, dizziness , headache & vertigo Misc :  fever Adverse Reactions/Side Effects:

30. Mother: Weakness Fatigue Muscle cramps Hypokalemia Postural hypotension Fetus : Diminished placental perfusion Thrombocytopenia Hyponatremia

31. Blurred vision Dizziness H eadache Tinnitus,Vertigo Itching Consti pation Dihea rhea Nea sea & Vomiting U rination M uscle cramps D ehydration Common Minor Side Effects:

32. In hepatic coma and in states of electrolyte depletion, therapy should not be instituted until the basic condition is improved. Sudden alterations of fluid and electrolyte balance in patients with cirrhosis may precipitate hepatic coma; therefore, strict observation is necessary during the period of diuresis. Supplemental potassium chloride and, if required, an aldosterone antagonist are helpful in preventing hypokalemia and metabolic alkalosis. If increasing azotemia and oliguria occur during treatment of severe progressive renal disease, furosemide should be discontinued. Cases of tinnitus and reversible or irreversible hearingimpairment and deafness have been reported. Reports usually indicate that furosemide ototoxicity is associated with rapid injection, severe renal impairment, the use of higher than recommended doses, hypoproteinemia or concomitant therapy with aminoglycoside antibiotics,ethacrynic acid, or other ototoxic drugs. If the physician elects to use high dose parenteral therapy,controlled intravenous infusion is advisable WARNINGS:

33. Patients with renal failure: For selected patients with advanced chronic renal failure, diuretic therapy may be started with furosemide orally. If conventional doses (80 to 160 mg orally) fail to produce an adequate diuresis, a single dose of 250 mg is given as a starting dose. If a satisfactory diuresis does not ensue within 4 to 6 hours, the initial dose may be doubled to 500 mg.

34. Patients with hypervolemia : For hypervolemic patients, it is advisable to give the high-dosage formulation of furosemide undiluted, or in a suitable volume (e.g., 250 mg in 50 mL) of infusion fluid so as to avoid the risk of overhydration . I.V. infusions of the undiluted solution must be given with the aid of a motor-driven precision syringe so as to make sure that the upper limit of furosemide 4 mg (0.4 mL)/minute is not achieved. DOSE ADJUSTMENT IN SPECIAL POPULATION:

35. Drug-Drug Interactions: ↑ risk of hypotension with   antihypertensives ,   nitrates , or acute ingestion of   alcohol . ↑ risk of hypokalemia with other   diuretics ,   amphotericin B ,   stimulant laxatives , and   corticosteroids . Hypokalemia may ↑ risk of   digoxin   toxicity and ↑ risk of arrhythmia in patients taking drugs that prolong the QT interval. ↓   lithium   excretion, may cause   lithium   toxicity. ↑ risk of ototoxicity with   aminoglycosides   or   cisplatin . ↑ risk of nephrotoxicity with   cisplatin .   NSAIDs   ↓ effects of furosemide. May ↑ risk of   methotrexate   toxicity. ↓ effects when given at same time as   sucralfate ,   cholestyramine , or   colestipol . INTERACTIONS:

36. ↑ risk of   salicylate   toxicity (with use of high-dose   salicylate   therapy). Concurrent use with   cyclosporine   may ↑ risk of gouty arthritis.

37. Drug-Disease Interactions: Loop Diuretics (Includes Furosemide) Anuria: Severe Potential Hazard,High plausibility Applies to Anuria The use of loop diuretics is contraindicated in patients with anuria. T herapy should be initiated in the hospital under strict observation in patients with liver cirrhosis and ascites. Sudden alteration of fluid and electrolyte balance may precipitate hepatic encephalopathy. Loop Diuretics (Includes Furosemide) Cirrhosis Severe Potential Hazard, High plausibility to Hepatic Coma, hepatic encephalopathy Loop Diuretics (Includes Furosemide) Electrolyte Losses Severe Potential Hazard, High plausibility Applies to: Hypocalcemia. Hypokalemia, Hyponatremia, Magnesium imbalance, Diarrhea. Electrolyte Abnormalities. Hyperaldosteronism. Ma l nourished, Ventricular Arrhythmia Vomiting, Dehydration. The use of loop diuretics, is commonly associated with loss of electrolytes, incl K, Na, CI, Mg, Ca, may lead to cardiac arrhythmias & cardiac arrest.Other complications aremetabolic alkalosis & hyponatremia, weight loss. dehydration

38. Loop Diuretics (Includes Furosemide) Renal Dysfunction Severe Potential Hazard, High plausibility Applies to Renal Dysfunction Impaired effectiveness and possible delayed excretion of loop diuretics may occur in patients with severe renal dysfunction. The use of furosemide has been associated with exacerbation or activation of systemic lupus erythematosus. Furosemide (Includes Furosemide) Lupus Erythematosus Moderate Potential Hazard, Moderate plausibility Applies to lupus erythematosus . Lupus Loop Diuretics (Includes Furosemide) Hyperuricemia Moderate Potential Hazard High plausibility Applies to Gout Loop diuretics may decrease the rate of uric acid excretion. Hyperuricemia can occur but is usually except in patients with atasymptomatic and rarely leads to clinical gout history of gout or chronic renal failure.

39. Food does not appear to affect diuretic effect. But with caution....... Avoid alcohol.Furosemide and ethanol may have additive effects in lowering your blood pressure. You may experience headache, dizziness, lightheadedness, fainting, and/or changes in pulse• Avoid excess salt/sodium unless otherwise instructed by your physician. Increase potassium intake; add a banana or orange juice; unless instructed otherwise. Take with food to reduce irritation. Drug-Food Interactions:

40. Signs & Symptoms : intravascular volume depletion; dehydration, hypokalemia and other eletrolyte disturbances , blood volume reduction, hypotension, hypokalemia and hypochloremic alkalosis, and are extensions of its diuretic action. LD50: The oral LD50 exceeded 1000 mg/kg body weight, while the IV LD50 ranged from 300 to 680 mg/kg. Toxicity: The concentration of LASIX in biological fluids associated with toxicity or death is not known. Missed dose: If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up. TOXICOLOGY:

41. Treatment of overdosage is supportive and consists of replacement of excessive fluid and electrolyte losses. Serum electrolytes, carbon dioxide level and blood pressure should be determined frequently. Adequate drainage must be assured in patients with urinary bladder outlet obstruction Hemodialysis does not accelerate furosemide elimination. MANAGEMENT OF OVERDOSAGE: Normal saline for volume replacement.Dopamine / nor-epinephrine may be used to treat hypotension.If dysrrythmia occur due to decreased potassium or magnesium is suspected to replace aggressively .

42. NURSING CONSIDERATIONS: Assess the weight of the client daily. Maintain the intake output record sheet to determine fluid loss. Monitor the vital signs: Especially respiration: rate, depth and rhythm. Blood pressure: Lying and standing. Monitor electrolytes, renal and hepatic function, serum glucose, and uric acid levels before and periodically throughout therapy. Commonly ↓ serum potassium. May cause ↓ serum sodium, calcium, and magnesium concentrations. May also cause ↑ BUN, serum glucose, serum creatinine, and uric acid levels. Administer the drug in the morning to avoid interference with sleep. It should be taken with food. Potassium levels are to be monitored, if found to be less than 3.0 mEq / L,then potassium is replaced. Check for improvement in edema, of feet, legs and sacral area.

43. Monitor for hematuria- may be a sign of renal calculi Note for: Signs of metabolic acidosis, i.e. drowsiness, restlessness. Signs of hypocalcemia Signs of postural hypotension. Notify if the client develops: Fatigue and malaise, dizziness. Tachycardia, nausea. Leg cramps, weakness. Rashes and temperature elevation. Advise the client to increase fluid intake to 2-3 L/day unless contraindicated. Tell the client to rise slowly from lying or sitting position. Regular assessment of patient condition is an important part of nursing consideration.

44. FDA's pregnancy category:Category C Furosemide has been shown to cause unexplained maternal deaths and abortions in rabbits at 2, 4 and 8 times the maximal recommended human dose. The lowest dose of 25 mg/kg((2 times the maximal recommended human dose of 600mg/day) Dose of 50 mg/kg (4 times the maximal recommended human dose of 600 mg/day) Treatment during pregnancy requires monitoring of fetal growth because of the potential for higher birth weights. Nursing mothers: Because it appears in breast milk, caution should be exercised when Furosemide is administered to a nursing mother. Furosemide may inhibit lactation. SPECIAL CONSIDERATIONS FOR PREGNANT WOMEN:

45. In premature infants furosemide may precipitate nephrocalcinosis / nephrolithiasis.II . If furosemide is administered to premature infants during the first weeks of life, it may increase the risk of persistence of patent ductus arteriosus. Geriatric Use: Controlled clinical studies of furosemide did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. In general, dose selection for the elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal or cardiac function, and of concomitant disease or other drug therapy. This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection and it may be useful to monitor renal function. Pediatric use:

46. BEFORE: check doctor's order. Assess allergy to furosemide, sulfonamides, tartrazine. Do not mix parenteral solution with highly acidic solutions with ph below3.5 . Do not expose to light, which may discolour tablets or solution. Educate the patient about the purpose and importance of the drug. NURSING RESPONSIBILITIES:

47. DURING: Check the patency of the IV site and IV line. Give early in the day so that increased urination will not disturb patient’s sleep. Administer the right dose at the right time. Measure and record weight to monitor fluid changes.

48. AFTER: Monitor blood glucose levels. Monitor vital signs closely. Monitor I & O closely. Arrange to monitor serum electrolytes, hydration, liver and renal function. Arrange for potassium-rich diet or supplemental potassium as needed. Report loss or gain of more than 1.5kg in 1day, swelling in patient’s ankles or fingers, unusual bleeding or bruising immediately to the physician. Document and record.

49. Assess fluid status. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. Notify health care professional if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs. Monitor BP and pulse before and during administration. Monitor frequency of prescription refills to determine compliance in patients treated for hypertension. Geri:  Diuretic use is associated with increased risk for falls in older adults. Assess falls risk and implement fall prevention strategies. Assess patients receiving digoxin for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Patients taking digoxin are at increased risk of digoxin toxicity because of the potassium-depleting effect of the diuretic. Potassium supplements or potassium-sparing diuretics may be used concurrently to prevent hypokalemia. Assess patient for tinnitus and hearing loss. Audiometry is recommended for patients receiving prolonged high-dose IV therapy. Hearing loss is most common after rapid or high-dose IV administration in patients with decreased renal function or those taking other ototoxic drugs. Assess for allergy to sulfonamides. Assess patient for skin rash frequently during therapy. Discontinue furosemide at first sign of rash; may be life-threatening. Stevens-Johnson syndrome, toxic epidermal necrolysis, or erythema multiforme may develop. Treat symptomatically; may recur once treatment is stopped. NURSING ASSESSMENT:

50. Excess fluid volume (Indications)   Deficient fluid volume (Side Effects) Potential Diagnoses:

51. Do not confuse Lasix (furosemide) with Luvox (fluvoxamine). If administering twice daily, give last dose no later than 5  pm  to minimize disruption of sleep cycle. IV route is preferred over IM route for parenteral administration. PO May be taken with food or milk to minimize gastric irritation. Tablets may be crushed if patient has difficulty swallowing. Do not administer discolored solution or tablets. IV Administration IV Push:     Diluent:  Administer undiluted (larger doses may be diluted and administered as intermittent infusion [see below]).  Concentration:  10 mg/ mL. Rate: Administer at a rate of 20 mg/min. Pedi:  Administer at a maximum rate of 0.5–1 mg/kg/min (for doses <120 mg) with infusion not exceeding 10 min. Implementation :

52. Intermittent Infusion: Diluent : Dilute larger doses in 50 mL of D5W, D10W, D20W, D5/0.9% NaCl , D5/LR, 0.9% NaCl , 3% NaCl , or LR. Infusion stable for 24 hr at room temperature. Do not refrigerate. Protect from light.   Concentration:   1 mg/ mL. Rate:  Administer at a rate not to exceed 4 mg/min (for doses >120 mg) in adults to prevent ototoxicity. Pedi:   not to exceed 1 mg/kg/min with infusion not exceeding 10 min. Use an infusion pump to ensure accurate dose. Y-Site Compatibility: Acyclovir Ascorbic acid Amikacin Y-Site Incompatibility: Alemtuzumab Diazepam ciprofloxacin

53. Patient/Family Teaching :

54. Instruct patient to take furosemide as directed. Take missed doses as soon as possible; do not double doses. Caution patient to change positions slowly to minimize orthostatic hypotension. Caution patient that the use of alcohol, exercise during hot weather, or standing for long periods during therapy may enhance orthostatic hypotension. Instruct patient to consult health care professional regarding a diet high in potassium. Advise patient to contact health care professional if weight gain >3 lbs in 1 day. Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking any OTC medications concurrently with this therapy. Instruct patient to notify health care professional of medication regimen before treatment or surgery. Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions. Advise patient to contact health care professional immediately if rash, muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs. Advise diabetic patients to monitor blood glucose closely; may cause increased blood glucose levels. Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected, or if breast feeding. Monitor fetal growth during pregnancy; increased risk for higher birth weights. Emphasize the importance of routine follow-up examinations.

55. Geri:   Caution older patients or their caregivers about increased risk for falls. Suggest strategies for fall prevention . Hypertension: Advise patients on antihypertensive regimen to continue taking medication even if feeling better. Furosemide controls but does not cure hypertension. Reinforce the need to continue additional therapies for hypertension (weight loss, exercise, restricted sodium intake, stress reduction, regular exercise, moderation of alcohol consumption, cessation of smoking).

56. Effect evident within 5 minutes after IV administration, 1 hour after PO: duration of action 2-4hours. Solution compatibility: NS & sterile water for direct IV injection; mix with D 5 W for continuous IV infusion . May provoke hyperglycemia or glucosuria , but to lesser extent than thiazide diuretics . Special Calculations :

57. Furosemide is an effective medication at treating ailments such as: Congestive Heart Failure, liver disease, high blood pressure, or kidney disease, it also can cause a lot of harm to the body even if taken correctly. Furosemide is not associated with any significant clinical benefits in the prevention and treatment of acute renal failure in adults. High doses may be associated with an increased risk of ototoxicity. CONCLUSION:

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