Are intravenous (IV) fluids and intravenous (IV) diuretics administered concurrently in certain clinical situations?

From the Guidelines

Yes, there are situations where it is acceptable to give IV fluids and IV diuretics together, particularly in patients with acute decompensated heart failure who have significant fluid overload but are also experiencing intravascular volume depletion or renal dysfunction, as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. This approach is commonly used in specific examples such as administering furosemide (typically 20-40mg IV) alongside careful fluid replacement (often with normal saline or lactated Ringer's at controlled rates) in patients with heart failure who have developed prerenal azotemia or in those with cardiorenal syndrome. The rationale behind this seemingly contradictory approach is that while the patient has overall fluid overload, their effective circulating volume may be reduced, leading to poor renal perfusion. By providing some IV fluids, renal blood flow improves, allowing the diuretics to work more effectively at removing excess fluid from the body. This approach requires careful monitoring of:

• fluid status
• urine output
• electrolytes (particularly potassium, sodium, and magnesium)
• renal function The timing and rate of administration are crucial - often the fluids are given at a controlled rate while diuretics are administered as intermittent boluses or continuous infusions depending on the clinical situation, as supported by the 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults 1. It is essential to note that the use of IV fluids and IV diuretics together should be individualized and based on the patient's specific clinical condition, with careful consideration of the potential risks and benefits, and guided by the most recent and highest quality evidence available.

From the FDA Drug Label

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.

• Intravenous (IV) fluids such as Sodium Chloride Injection USP, Lactated Ringer's Injection USP, or Dextrose (5%) Injection USP can be administered concurrently with intravenous (IV) diuretics like furosemide in certain clinical situations, specifically when using high dose parenteral therapy 2.
• This is done by adding furosemide to the IV fluid and administering it as a controlled infusion.
• The key consideration is to ensure the pH of the prepared infusion solution is in the weakly alkaline to neutral range to prevent precipitation of the furosemide.

From the Research

Administration of IV Fluids and Diuretics

• In certain clinical situations, IV fluids and diuretics can be administered concurrently, as seen in the study by 3, which evaluated the efficacy of simultaneous hypertonic saline solution and IV furosemide for patients with fluid overload.
• The use of IV diuretics, such as furosemide, can be effective in managing volume overload in heart failure patients, as demonstrated in the study by 4, which found significant urine output and weight loss in patients receiving IV diuretic treatment.
• The administration of IV fluids and diuretics can be tailored to individual patient needs, taking into account factors such as fluid status, renal function, and disease severity, as discussed in the study by 5, which emphasized the importance of careful fluid management in critically ill patients.

Clinical Situations for Concurrent Administration

• Acute decompensated heart failure is one clinical situation where concurrent administration of IV fluids and diuretics may be beneficial, as seen in the study by 3, which found improved outcomes in patients receiving simultaneous hypertonic saline solution and IV furosemide.
• Volume overload is another clinical situation where concurrent administration of IV fluids and diuretics may be effective, as demonstrated in the study by 4, which found significant urine output and weight loss in patients receiving IV diuretic treatment for volume management.
• Critically ill patients may also benefit from careful fluid management, including the concurrent administration of IV fluids and diuretics, as discussed in the study by 5, which emphasized the importance of tailoring fluid therapy to individual patient needs.

Considerations for Concurrent Administration

• The choice of IV fluid and diuretic, as well as the dosage and administration schedule, should be carefully considered, taking into account individual patient factors and disease processes, as discussed in the study by 5.
• Monitoring of patient response, including urine output, weight loss, and renal function, is essential when administering IV fluids and diuretics concurrently, as seen in the studies by 3 and 4.
• The potential for adverse effects, such as hypokalemia and worsening renal function, should be carefully monitored and managed, as discussed in the studies by 3 and 6.