Heart failure: continuous furosemide infusion was not clearly better than intermittent bolus.

Clinical bottom line (level 2b-)

  1. Patients with heart failure who were given protocol-guided management with a continuous infusion of furosemide, had no clear difference in ability to achieve net fluid balance than those given an intermittent bolus.
  2. Patients given a continuous infusion of furosemide, had slightly better outcome in mortality than those given an intermittent bolus. (NNT = 8 at unknown)
Schuller et al: Critical Care Medicine 1997; 25 (12): 1969-1975
Expires October 2003

The study

Unblinded ?concealed quasi-randomised trial with intention-to-treat
Setting: medical intensive care units and cardiac care units of 2 hospitals, USA

33 patients (aged mean 64 years, 91% male) clinical condition for which aggressive intravenous diuresis was intended (as determined by the medical team)

Excluded if
  • lack of informed consent
  • investigator staff not available
  • diuresis efforts already underway
  • <18 or >85 years old
  • pregnancy
  • history of allergic reaction or intolerance to furosemide
  • receiving any renal replacement therapy such as haemodialysis, peritoneal dialysis, continuous arteriovenous haemodialysis, slow continuous ultrafiltration or history of kidney transplantation
  • clinical evidence of hypovolaemia
  • hypotension with a systolic blood pressure of <90 mmHg or clinical evidence of hypoperfusion
  • uncorrected hypokalaemia
  • history of metastatic cancer, cancer considered to be refractory to treatment, severe organic brain syndrome or severe neurologic injury known to be associated with poor prognostic outcome
  • do-not-resucitate order
  • participation in another research protocol


    • Control Group: (n = 14, 14 analysed): continuous infusion of furosemide
    Experimental Group: (n = 19, 19 analysed): bolus infusion of furosemide
    All patients received an initial bolus infusion of furosemide (40 mg) and minimisation of fluid intake was implemented. Diuresis protocol was based on a specified algorithm that was centred on the patient's net hourly fluid balance. Both regimens were titrated individually to an hourly net fluid balance goal of at least -1 mL/kg. Once this was achieved, the dosing was adjusted if necessary to ensure that the hourly fluid balance was at least -1 mL/kg until the therapeutic endpoint, the therapy was discontinued, the patient transferred out of the ICU or 72 hours in the study had elapsed.
    100% followed for ?
    Outcome notes:
    • achieved net fluid balance : at least an average hourly balance of -1 mL/kg

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNH
    (95% CI)
    achieved net fluid balance unknown 13
    (92.9%)    		 18
    (94.7%)    		 26%
    (-980% to 95%)    		 1.88%
    (-14.9% to 18.7%)    		 53
    (NNT = 7 to infinity;
    NNH = 5 to infinity)
    death unknown 2
    (14.3%)    		 5
    (26.3%)    		 -84.0%
    (-715% to 58.0%)    		 -12.0%
    (-39.0% to 15.0%)    		 8
    (NNT = 3 to infinity;
    NNH = 7 to infinity)

    Comments

    1. The study is too small to show any clear difference between the two therapies.

    Citation

    1. Schuller D, Lynch JP, Fine D: Protocol-guided diuretic management: Comparison of furosemide by continuous infusion and intermittent bolus. Critical Care Medicine 1997; 25 (12): 1969-1975
    Contributor: Clare Wotton and Musab Hayatli, October 1999
    Reviewer:

    Clinical Question.
    Patient pulmonary edema oedema
    Intervention or Exposure continuous infusion of furosemide
    Comparison intermittent bolus of furosemide
    Outcome safety and efficacy