How should I manage a patient with severe heart failure (ejection fraction ~30%) and right‑ventricular dysfunction who is volume overloaded on intravenous furosemide, has type 2 diabetes, recently had a hypoglycemic seizure while on insulin and dextrose infusion, and is receiving thiamine, rabeprazole, ceftriaxone, and ondansetron?

Management of Severe Heart Failure with Biventricular Dysfunction and Volume Overload

Continue IV furosemide with aggressive dose escalation targeting urine output >150 mL/hour, while immediately initiating or optimizing guideline-directed medical therapy (ACE inhibitor/ARB and beta-blocker) unless hemodynamically unstable, and address the hypoglycemia by discontinuing insulin/dextrose and managing diabetes with safer alternatives. 1, 2

Immediate Diuretic Management

IV Furosemide Dosing Strategy

• Since the patient is already on IV furosemide, escalate the dose by 20 mg increments every 2 hours if inadequate response, with maximum doses reaching 600 mg/day (oral equivalent; IV dosing proportionally lower due to superior bioavailability) 1
• Target urine output of 150+ mL/hour continuously, with daily weight loss of 0.5-1.0 kg until volume overload resolves 1
• Administer as either intermittent boluses or continuous infusion—both are equally acceptable, adjusting dose and duration according to symptoms and clinical status 2

Critical Monitoring Parameters

• Monitor hourly: urine output (target >100-150 mL/hour), signs of hypoperfusion (cool extremities, altered mental status, oliguria) 1
• Monitor daily: weight (target 0.5-1.0 kg loss), serum creatinine, electrolytes (especially potassium and magnesium), blood pressure 2, 1
• Hold diuretics temporarily only if: SBP <90 mmHg with signs of hypoperfusion, but rule out hypovolemia or other correctable causes first 1

Common Pitfall: Underdosing

Underdosing is the most common error, leading to inadequate diuresis and refractory edema—low doses diminish response to ACE inhibitors and increase risk with beta-blockers 1. If azotemia or hypotension occurs before treatment goals are met, slow the rate of diuresis but maintain it until fluid retention is eliminated 1.

Guideline-Directed Medical Therapy (GDMT)

Foundational Neurohormonal Blockade

Every attempt should be made to continue or initiate evidence-based disease-modifying therapies unless hemodynamic instability or contraindications exist 2:

• ACE inhibitors (or ARBs if ACE-intolerant): Recommended for all patients with HFrEF to improve symptoms, reduce morbidity and mortality 2
• Beta-blockers (bisoprolol, carvedilol, or metoprolol succinate): Recommended for all stable patients with HFrEF to reduce mortality 2, 1
• Continue these medications unless the patient is symptomatically hypotensive or hypoperfused 2

Second-Line Therapy

• Aldosterone antagonists (spironolactone or eplerenone): Recommended for patients with NYHA class II-IV and LVEF ≤35% to reduce mortality and hospitalization 2
• Requires close monitoring of potassium levels and renal function 2

Avoid Harmful Medications

Thiazolidinediones (glitazones) are contraindicated in patients with HF as they increase risk of HF worsening and hospitalization 2. NSAIDs and COX-2 inhibitors are similarly contraindicated 2.

Management of Right Ventricular Dysfunction

Inotropic Support Considerations

Inotropic agents are NOT recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 2. If hypoperfusion persists despite adequate volume status, consider short-term inotropic support (dobutamine, dopamine, or levosimendan) 1.

Device Therapy Evaluation

Once stabilized and after 3-6 months of optimal GDMT, evaluate for:

• Cardiac resynchronization therapy (CRT): Recommended if QRS ≥150 msec with LBBB morphology and LVEF ≤35% to improve symptoms and reduce morbidity/mortality 2
• Implantable cardioverter-defibrillator (ICD): Recommended if LVEF ≤35% (not within 40 days of MI) to reduce sudden death 2

Diabetes Management Adjustments

Immediate Hypoglycemia Management

• Discontinue insulin and dextrose infusion immediately given recent hypoglycemic seizure
• Transition to safer glucose-lowering agents once stable

SGLT2 Inhibitors as Preferred Therapy

Consider adding an SGLT2 inhibitor (empagliflozin or dapagliflozin) once euvolemic, as these agents:

• Significantly reduce cardiovascular and all-cause mortality irrespective of diabetes status 3
• Provide synergistic natriuretic effects with loop diuretics without neurohormonal activation 4
• Improve blood volume without potassium wasting or renal dysfunction 4, 5
• Show significant improvement in dyspnea scores and weight loss when added to furosemide 5

Medication Review

Continue Essential Supportive Medications

• Thiamine: Continue for nutritional support, especially if alcohol use or malnutrition suspected
• Rabeprazole: Continue for gastroprotection if indicated
• Ceftriaxone: Continue if infection present; reassess need daily
• Ondansetron: Use as needed for nausea, but avoid routine use

Monitoring and Follow-Up

Short-Term (Daily During Hospitalization)

• Symptoms, urine output, daily weights, renal function, electrolytes 2
• Clinical status assessment for signs of hypoperfusion or worsening congestion 1

Medium-Term (1-2 Weeks Post-Discharge)

• Clinic visit or virtual visit with basic metabolic panel to assess GDMT titration 2
• Continue medication adjustments until no further changes possible or tolerated 2

Long-Term Considerations

Refer to advanced heart failure specialist if 2:

• Need for chronic IV inotropes
• Persistent NYHA class III-IV symptoms despite GDMT
• Two or more hospitalizations for HF in prior 12 months
• Progressive intolerance or down-titration of GDMT
• Systolic BP <90 mmHg or symptomatic hypotension

Multidisciplinary Care

Enroll patient in a multidisciplinary care management program to reduce risk of HF hospitalization and mortality 2. Once stable, encourage regular aerobic exercise to improve functional capacity and reduce hospitalization risk 2.