Starting Dose for Bumetanide Continuous Infusion
The starting dose for a bumetanide continuous infusion in adults is 1 mg/hour, based on the mean effective dose identified in systematic review of clinical practice. 1
Initial Dosing Strategy
Start with 1 mg/hour as the initial infusion rate for most adult patients with acute heart failure or volume overload. 1 This represents the mean dose used across multiple studies and provides a balance between efficacy and safety.
Dosing Range and Titration
- The typical dosing range for bumetanide continuous infusion is 0.5-1.5 mg/hour, with 1 mg/hour representing the average effective dose. 1
- Treatment duration typically extends for 45 hours on average, though this should be adjusted based on clinical response. 1
- Higher doses correlate with increased urine output but also increased risk of acute kidney injury (AKI), so start conservatively and titrate based on response. 1
Expected Clinical Response
- Target urine output is approximately 1.88 mL/kg/hour (roughly 130-150 mL/hour for a 70 kg patient) with continuous bumetanide infusion. 1
- Diuretic effect begins within 30 minutes and persists for 3-6 hours per dose equivalent. 2
- Monitor for adequate diuresis within the first few hours; if insufficient, consider increasing the infusion rate rather than switching to bolus dosing. 1
Critical Monitoring Requirements
Check the following parameters closely during continuous infusion:
- Renal function and electrolytes within 1-2 weeks after starting therapy, including serum creatinine, sodium, and potassium. 3
- Daily weights targeting 0.5-1.0 kg loss per day to assess volume status. 4
- Watch for signs of volume depletion including hypotension, dizziness, and prerenal azotemia. 4
- Monitor for hypokalemia and hypomagnesemia, which predispose to arrhythmias; magnesium must be corrected before potassium repletion will be effective. 3
Safety Considerations and AKI Risk
- The incidence of AKI with continuous bumetanide infusion is approximately 25%, so close monitoring is essential. 1
- Increasing doses correlate with higher AKI risk, independent of urine output achieved. 1
- Consider potassium supplementation or aldosterone antagonist (spironolactone 12.5-25 mg daily) from the start to prevent electrolyte derangements. 4
Maximum Dosing Limits
- Total daily dose should not exceed 10 mg regardless of administration method (bolus or continuous infusion). 5, 4
- At 1 mg/hour, this maximum would be reached after 10 hours of continuous infusion, so plan to either reduce the rate or transition to intermittent dosing. 5
- If 10 mg/day is ineffective, add thiazide diuretics for sequential nephron blockade rather than exceeding the maximum bumetanide dose. 3, 4
Common Pitfalls to Avoid
- Avoid combining with NSAIDs, which block diuretic effects and worsen renal function. 3
- Do not ignore dietary sodium intake; patients consuming high sodium may appear resistant to therapy. 3
- Do not continue infusion beyond 10 mg total daily dose; instead, add combination therapy with thiazides if resistance develops. 3, 4
- Prepare solutions freshly and use within 24 hours when mixing with IV fluids. 5