How to manage a patient with hypotension and volume overload who requires intravenous (IV) furosemide (Lasix), but cannot receive vasopressors or inotropes?

From the Guidelines

For a patient with hypotension (90/60) who is fluid overloaded and congested requiring diuresis, but cannot receive vasopressors or inotropes, I recommend proceeding with low-dose furosemide administered as a continuous infusion rather than bolus dosing, as this approach allows for gentler diuresis while minimizing acute blood pressure drops. The initial approach to congestion management involves i.v. diuretics, and according to the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1, the dose should be limited to the smallest amount to provide adequate clinical effect and modified according to previous renal function and previous dose of diuretics. Start with a loading dose of 20-40 mg IV furosemide followed by a continuous infusion at 5-10 mg/hour, titrating slowly based on urine output and blood pressure response, as suggested by the guidelines 1. Some key points to consider when administering furosemide in this context include:

• Monitoring blood pressure every 15-30 minutes initially, along with strict intake/output measurements, daily weights, and electrolytes (particularly potassium, sodium, and magnesium) every 4-6 hours, as recommended by the 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults 1.
• Positioning the patient with legs elevated and ensuring adequate oral sodium intake (if not contraindicated) may help maintain blood pressure during diuresis.
• If blood pressure falls below 85/55 mmHg, consider temporarily reducing or pausing the infusion until blood pressure stabilizes. This approach balances the competing needs of removing excess fluid while avoiding dangerous hypotension in a hemodynamically vulnerable patient, and is supported by the most recent and highest quality evidence available 1.

From the FDA Drug Label

The usual initial dose of furosemide is 40 mg injected slowly intravenously (over 1 to 2 minutes). If a satisfactory response does not occur within 1 hour, the dose may be increased to 80 mg injected slowly intravenously (over 1 to 2 minutes).

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 intravenous dose should be given slowly (1 to 2 minutes).

The patient has a blood pressure of 90/60 and is congested and overloaded, indicating the need for IV furosemide. Given the patient's hypotensive state, caution should be exercised when administering furosemide. The initial dose of 40 mg IV can be considered, administered slowly over 1 to 2 minutes. Close monitoring of the patient's blood pressure and electrolyte levels is necessary. If a satisfactory response does not occur within 1 hour, the dose may be increased to 80 mg IV, also administered slowly over 1 to 2 minutes 2.

From the Research

Patient Management

The patient's blood pressure is 90/60, indicating hypotension, and they are congested and overloaded, requiring IV furosemide. However, they cannot take vasopressors or inotropes.

Considerations for Furosemide Administration

• Furosemide is a loop diuretic that can help reduce fluid overload and congestion.
• The patient's hypotension may be a concern when administering furosemide, as it can further decrease blood pressure.
• There is no direct evidence in the provided studies to guide the administration of furosemide in this specific scenario, as the studies primarily focus on vasopressor and inotrope therapy 3, 4, 5, 6, 7.

Potential Approach

• Monitor the patient's blood pressure and fluid status closely when administering furosemide.
• Consider starting with a low dose of furosemide and titrating as needed to avoid exacerbating hypotension.
• Be prepared to adjust the patient's management plan if their condition changes or if they show signs of worsening hypotension or fluid overload.

Limitations

• The provided studies do not offer specific guidance on managing patients with hypotension and fluid overload who cannot receive vasopressors or inotropes.
• Further research or consultation with a healthcare expert may be necessary to determine the best course of action for this patient.