Can I administer intravenous (IV) fluids and oral (PO) diuretics simultaneously?

From the Guidelines

Yes, you can administer intravenous (IV) fluids and oral (PO) diuretics simultaneously, but with caution and careful monitoring of the patient's clinical status, particularly in patients with heart failure 1.

Key Considerations

• The use of IV diuretics is a cornerstone in the treatment of patients with acute heart failure (AHF) and signs of fluid overload and congestion 1.
• In patients with AHF and signs of hypoperfusion, diuretics should be avoided before adequate perfusion is attained 1.
• The initial approach to congestion management involves IV diuretics with the addition of vasodilators for dyspnoea relief if blood pressure allows 1.
• IV fluids may be necessary to maintain adequate perfusion, but careful monitoring of the patient's volume status and renal function is essential to avoid worsening congestion or renal dysfunction 1.

Monitoring and Adjustments

• Regular observation of the patient's symptoms, heart rate, blood pressure, urine output, and oxygen saturation is crucial to adjust the treatment plan as needed 1.
• The dose of diuretics should be limited to the smallest amount to provide adequate clinical effect and modified according to previous renal function and previous dose of diuretics 1.
• In patients with persistently low blood pressure or shock, alternative diagnoses and treatments should be considered, including the use of inotropes or vasopressors 1.

Evidence-Based Recommendations

• The European Society of Cardiology (ESC) guidelines recommend the use of IV diuretics in patients with AHF and signs of fluid overload and congestion, with careful monitoring of the patient's clinical status 1.
• The American Heart Association (AHA) and other guidelines also recommend the use of diuretics in the treatment of heart failure, with careful attention to the patient's volume status and renal function 1.

From the Research

Administration of IV Fluids and Oral Diuretics

• The administration of intravenous (IV) fluids and oral (PO) diuretics simultaneously is a complex topic, and the evidence is not straightforward 2, 3, 4, 5, 6.
• A study published in 2021 found that the simultaneous use of hypertonic saline solution and IV furosemide was associated with lower all-cause mortality and heart failure-related readmissions compared to IV furosemide alone in patients with fluid overload 2.
• However, another study published in 2010 highlighted the controversy regarding fluid management in patients with septic acute kidney injury and cardiorenal syndromes, and emphasized the need for accurate assessment of fluid status and careful definition of targets to improve clinical outcomes 3.
• A 2023 observational study found that the time of administration of IV diuretics affected outcomes in patients with heart failure, and that early initiation and subsequent modification of appropriate congestion treatment was critical for prognostic improvement 4.
• A 2016 study evaluated the effectiveness of IV diuretic treatment for volume management in heart failure patients and found that it was safe and associated with significant urine output and weight loss across a wide range of maintenance diuretic doses and ejection fractions 5.
• In contrast, a 2015 retrospective cohort study found that the use of IV fluids in the early care of patients with acute decompensated heart failure who were treated with loop diuretics was associated with worse outcomes, including higher rates of subsequent critical care admission, intubation, renal replacement therapy, and hospital death 6.

Key Considerations

• The use of IV fluids and oral diuretics simultaneously should be carefully considered on a case-by-case basis, taking into account the individual patient's fluid status, renal function, and overall clinical condition 2, 3, 4, 5, 6.
• Accurate assessment of fluid status and careful definition of targets are crucial to improve clinical outcomes in patients with fluid overload and heart failure 3, 4.
• The timing and dosage of IV diuretics and IV fluids should be carefully managed to minimize the risk of adverse outcomes 4, 5, 6.