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Evidence summaries

Continuous Infusion or Intermittent Bolus Administration of Loop Diuretics in Acutely Decompensated Heart Failure

Continuous infusion and intermittent bolus of furosemide may have similar effect on patient assessment of symptoms, but continuous infusion of loop diuretics may provide greater diuresis and a better safety profile as compared to single intravenous bolus administration in acutely decompensated heart failure. Level of evidence: "C"

The quality of evidence is downgraded by study quality (inadequate or unclear allocation concealment) and by imprecise results (few patients and wide confidence intervals).

Summary

A Cochrane review [Abstract] 1 included 8 studies with a total of 254 subjects. The studies compared the efficacy of continuous intravenous infusion versus bolus intravenous administration of loop diuretics in congestive heart failure.

In 7 studies which reported on urine output, the output (as measured in cc/24 hours) was noted to be greater in patients given continuous infusion (WMD 271 cc/24 hour, 95% CI 93.1 to 449; 7 studies, n=221, statistical heterogeneity, I2 =73%). Electrolyte disturbances (hypokalemia, hypomagnesemia) were not significantly different in the two treatment groups (RR 1.47,95% CI 0.52 to 4.15; 3 studies, n=71). Less adverse effects (tinnitus and hearing loss) were noted with continuous infusion (RR 0.06, 95% CI 0.01 to 0.44; 5 studies, n=218). The duration of hospital stay was shortened by 3.1 days with continuous infusion (WMD -3.1 days, 95% CI -4.06 to -2.20 days; 1 study, n=107). All cause mortality was reduced in the infusion group (RR 0.52, 95% CI 0.38 to 0.71; 2 studies, n=140), as was cardiac mortality (RR 0.47, 95% CI 0.33 to 0.69; 1 study, n=107). The existing data does not allow definitive recommendations for clinical practice.

A prospective, double-blind, randomized trial 2 including 308 subjects with acute decompensated heart failure compared intravenous furosemide administered by a bolus every 12 hours or by continuous infusion and at either a low dose (equivalent to the patient's previous oral dose) or a high dose (2.5 times the previous oral dose). There was no significant difference in patients' global assessment of symptoms or in the mean change in the creatinine level between bolus administration and continuous infusion. In the comparison of the high-dose strategy with the low-dose strategy, there was a nonsignificant trend toward greater improvement in patients' global assessment of symptoms in the high-dose group (P=0.06). No significant difference in the mean change in the creatinine level was observed between the gropus.

References

  • Salvador DR, Rey NR, Ramos GC, Punzalan FE. Continuous infusion versus bolus injection of loop diuretics in congestive heart failure. Cochrane Database Syst Rev 2005 Jul 20;(3):CD003178. [PubMed]
  • Felker GM, Lee KL, Bull DA et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011;364(9):797-805. [PubMed]

Primary/Secondary Keywords