What is the common dosing schedule for using hypertonic saline in combination with a loop diuretic, such as Furosemide (Lasix), for refractory heart failure?

From the Guidelines

A common dosing schedule for hypertonic saline with loop diuretics in refractory heart failure typically involves administering 150-250 mL of 3% hypertonic saline over 30-60 minutes, followed by intravenous furosemide at doses of 80-160 mg. This combination is usually given once or twice daily for 3-5 days during acute decompensation episodes. The hypertonic saline should be administered via a central line or large peripheral vein to avoid vein irritation. Careful monitoring is essential, including daily weights, fluid intake/output, electrolytes (particularly sodium), and renal function, as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. The mechanism behind this approach involves the hypertonic saline temporarily expanding intravascular volume and improving renal perfusion, while also mobilizing fluid from the interstitial space into the vasculature. This enhances the effectiveness of the loop diuretic by increasing delivery of sodium to the nephron and overcoming diuretic resistance. Some key considerations for the use of diuretics in acute heart failure include:

• Regular monitoring of symptoms, urine output, renal function, and electrolytes during use of i.v. diuretics, as recommended by the 2016 ESC guidelines 1
• Initial recommended dose of 20–40 mg i.v. furosemide (or equivalent) for patients with new-onset AHF or those with chronic, decompensated HF not receiving oral diuretics, and at least equivalent to oral dose for those on chronic diuretic therapy 1
• Administration of diuretics either as intermittent boluses or a continuous infusion, with dose and duration adjusted according to the patient's symptoms and clinical status 1 This regimen should be used cautiously in patients with severe hyponatremia, and dose adjustments may be needed based on the patient's response and laboratory values. It is also important to note that inotropic agents are not recommended unless the patient is symptomatically hypotensive or hypoperfused because of safety concerns, as stated in the 2016 ESC guidelines 1.

From the Research

Dosing Schedule for Hypertonic Saline in Combination with Loop Diuretic

• The dosing schedule for using hypertonic saline in combination with a loop diuretic for refractory heart failure is not explicitly stated in the provided studies, but the studies suggest that the combination can be effective in improving diuretic responsiveness and urine output 2, 3, 4.
• One study used a dose of 125 mg, 250 mg, or 500 mg of furosemide diluted in 150 ml of hypertonic saline solution (1.4%) for 24 hours 2.
• Another study used a combination of hypertonic saline and low-dose furosemide to treat refractory congestive heart failure with hyponatremia, but the exact dosing schedule is not specified 3.
• A retrospective analysis of 58 hypertonic saline administration episodes in 40 patients with diuretic-therapy refractory ADHF found that hypertonic saline administration was associated with increased diuretic efficiency, fluid and weight loss, and improvement of metabolic derangements 4.

Key Findings

• The combination of hypertonic saline and loop diuretic has been shown to improve diuretic responsiveness and urine output in patients with refractory heart failure 2, 3, 4.
• Hypochloremia has been associated with reduced diuretic efficacy, and chloride repletion may enhance natriuretic and diuretic responses 5, 6.
• The addition of hypertonic saline to furosemide may improve short-term natriuretic response and outcomes in ambulatory patients with worsening heart failure and hypochloremia 6.