What is the protocol for volume loading then diuresing with Intravenous (IV) fluids to manage fluid overload and promote diuresis?

From the Guidelines

The protocol for managing fluid overload and promoting diuresis in patients with heart failure involves administering intravenous loop diuretics, such as furosemide, at a dose equal to or exceeding the patient's chronic oral daily dose, with careful monitoring of urine output, vital signs, and electrolytes. This approach is supported by the 2013 ACCF/AHA guideline for the management of heart failure, which recommends treating patients with heart failure and fluid overload with intravenous diuretics to reduce morbidity 1. The initial intravenous dose should be equal to or exceed the patient's chronic oral daily dose, and the dose should be adjusted based on urine output and signs and symptoms of congestion 1.

Key Considerations

• The goal of diuretic therapy is to eliminate clinical evidence of fluid retention, such as jugular venous pressure elevation and peripheral edema 2.
• Patients with heart failure may require increasing doses of diuretics as the disease progresses, and diuretic resistance can be overcome by intravenous administration, combination therapy, or use of drugs that increase renal blood flow 2.
• Careful monitoring of vital signs, urine output, and electrolytes is essential during diuretic therapy, and patients should be educated on how to modify their diuretic regimen in response to changes in weight or symptoms 3.
• The restriction of dietary sodium and fluid intake can also help maintain volume balance and reduce the risk of recurrence of fluid retention 3.

Monitoring and Adjustment

• Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension 1.
• Serum electrolytes, urea nitrogen, and creatinine should be measured during titration of diuretic therapy, and electrolyte imbalances should be treated aggressively 4.
• Patients who are sent home before achieving euvolemia are at high risk of recurrence of fluid retention and early readmission, and ongoing control of fluid retention may be enhanced by enrollment in a heart failure program 3.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Adults: Parenteral therapy with Furosemide Injection should be used only in patients unable to take oral medication or in emergency situations and should be replaced with oral therapy as soon as practical. The usual initial dose of furosemide is 20 to 40 mg given as a single dose, injected intramuscularly or intravenously The intravenous dose should be given slowly (1 to 2 minutes). If the physician elects to use high dose parenteral therapy, add the furosemide to either Sodium Chloride Injection USP, Lactated Ringer's Injection USP, or Dextrose (5%) Injection USP after pH has been adjusted to above 5. 5, and administer as a controlled intravenous infusion at a rate not greater than 4 mg/min.

The protocol for volume loading then diuresing with Intravenous (IV) fluids to manage fluid overload and promote diuresis using furosemide is not explicitly stated in the provided drug labels. Key points:

• The labels provide information on the dosage and administration of furosemide for edema and acute pulmonary edema.
• They do not provide a specific protocol for volume loading and diuresis. 5 6

From the Research

Protocol for Volume Loading and Diuresis

The protocol for volume loading followed by diuresis with intravenous (IV) fluids to manage fluid overload and promote diuresis involves several key considerations:

• The choice of IV fluid is crucial, with crystalloids being the most commonly used fluids for volume therapy 7.
• Balanced crystalloids (BC) are preferred over 0.9% sodium chloride due to their more physiological composition, which may reduce the risk of acute kidney injury, acidemia, and hyperchloremia 7.
• The use of colloids, such as albumin, is generally not recommended except in specific situations, such as patients with cirrhosis or sepsis 7.
• Fluid loading with crystalloids, such as 0.9% saline, may increase diuresis more than colloid fluid loading in critically ill patients with clinical hypovolemia 8.
• The correction of hypovolemia with crystalloid fluids should be individualized, taking into account the cause of hypovolemia, cardiovascular state, renal function, and coexisting acid-base and electrolyte disorders 9.

Key Considerations for IV Fluid Management

When managing IV fluid therapy, the following factors should be considered:

• The properties of various IV fluids and their impact on human physiology 10.
• The goals of fluid therapy, which should be defined based on the patient's clinical and laboratory assessments 10.
• The potential adverse effects of IV fluids, such as hyperchloremic metabolic acidosis and renal vasoconstriction associated with normal saline 9.
• The importance of monitoring the safety and efficacy of IV fluid therapy, with nurses playing a vital role in this process 10.

Diuresis and Edema Management

In the management of edema and fluid retention, the following strategies may be employed:

• The use of diuretics, such as furosemide, with or without albumin 11.
• The administration of intravenous 25% albumin plus furosemide to improve diuresis, oxygenation, and hemodynamic stability in critically ill, hypoalbuminemic patients 11.
• The consideration of individual patient factors, such as hypoalbuminemia and hemodynamic stability, when selecting a diuresis strategy 11.