From the Guidelines
For patients with heart failure, the recommended intravenous (IV) fluid bolus infusion rate is not explicitly stated in the provided guidelines, but a conservative approach is recommended, typically starting with a small bolus of 250-500 mL of isotonic crystalloid administered slowly over 1-2 hours. The guidelines from the European Society of Cardiology (ESC) 1 emphasize the importance of careful monitoring of symptoms, urine output, renal function, and electrolytes during the use of IV diuretics.
- The initial recommended dose of IV furosemide should be 20–40 mg (or equivalent) for patients with new-onset acute heart failure (AHF) or those with chronic, decompensated heart failure (HF) not receiving oral diuretics 1.
- For patients on chronic diuretic therapy, the initial IV dose should be at least equivalent to the oral dose 1.
- Diuretics can be given either as intermittent boluses or as a continuous infusion, with the dose and duration adjusted according to the patient's symptoms and clinical status 1. It is crucial to balance the need for volume resuscitation against the risk of precipitating or worsening heart failure, and to consider using inotropic support alongside judicious fluid administration in cases where the patient is both volume depleted and in heart failure.
- Inotropic agents, such as dobutamine or milrinone, may be considered in patients with hypotension (systolic blood pressure <90 mmHg) and/or signs of peripheral hypoperfusion 1.
- However, inotropic agents are not recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 1.
From the Research
Intravenous Bolus Infusion Rate in Heart Failure
The recommended intravenous (IV) bolus infusion rate in a patient with heart failure is not explicitly stated in the provided studies. However, the studies compare the effects of continuous infusion versus bolus injection of loop diuretics in acute heart failure.
Comparison of Continuous Infusion and Bolus Injection
- A study from 2014 2 found that continuous infusion of loop diuretics resulted in greater reductions in B-type natriuretic peptide (BNP) from admission to discharge, but this appeared to occur at the consequence of worsened renal filtration function, use of additional treatment, and higher rates of rehospitalization or death at six months.
- A Cochrane review from 2024 3 found that continuous intravenous infusion of loop diuretics may result in mean net weight loss of 0.86 kg more than bolus injection of loop diuretics, but the evidence is very uncertain.
- A study from 2004 4 found that continuous infusion of loop diuretics resulted in greater diuresis and a better safety profile compared to bolus injection, but the existing data does not allow definitive recommendations for clinical practice.
Key Findings
- There is no clear recommendation for the optimal IV bolus infusion rate in heart failure patients.
- Continuous infusion of loop diuretics may be associated with greater diuresis and a better safety profile compared to bolus injection, but the evidence is uncertain.
- The choice between continuous infusion and bolus injection of loop diuretics should be based on individual patient needs and clinical judgment, as the current evidence does not support a definitive recommendation for one method over the other 5, 2, 3, 4.