For an adult with acute decompensated heart failure receiving a continuous furosemide infusion, how long should the infusion be continued?

Duration of Continuous Furosemide Infusion in Acute Decompensated Heart Failure

Continue the furosemide infusion until clinical euvolemia is achieved—typically 24 to 72 hours—then transition to oral diuretic therapy as soon as the patient is hemodynamically stable and able to take oral medications. 1

Initial Assessment and Infusion Initiation

• Start with a 40 mg IV loading dose followed by continuous infusion at 5–10 mg/hour (maximum rate 4 mg/min) in patients with acute decompensated heart failure and volume overload 1
• Ensure systolic blood pressure is ≥90–100 mmHg before initiating therapy, as furosemide can worsen hypoperfusion in hypotensive patients 1
• Verify serum sodium is >125 mmol/L and confirm the patient is not anuric before starting the infusion 1

Target Response and Duration Benchmarks

• Assess diuretic response within the first 2–6 hours by measuring spot urine sodium content (target >50–70 mEq/L) and hourly urine output (target >100–150 mL/hour) 2, 1
• Aim for daily weight loss of 0.5–1.0 kg until dry weight is achieved, which typically requires 24–72 hours of continuous infusion 1, 3
• The first 48 hours are critical for achieving adequate decongestion; inadequate diuresis during this window should prompt dose escalation or addition of a second diuretic class 1, 3

Monitoring During Infusion

• Place a bladder catheter to monitor urine output hourly and rapidly assess treatment response 2, 1
• Check electrolytes (sodium, potassium) and renal function within 6–24 hours after starting the infusion, then every 3–7 days during active therapy 1
• Monitor for resolution of peripheral edema, pulmonary crackles, and jugular venous distension as clinical markers of successful decongestion 1

Dose Escalation for Inadequate Response

• If urine output remains <0.5 mL/kg/hour after 2 hours, double the infusion rate but do not exceed 100 mg in the first 6 hours or 240 mg in the first 24 hours 1
• If adequate diuresis is not achieved after 24–48 hours despite maximal loop diuretic therapy, add a second diuretic class (hydrochlorothiazide 25 mg, spironolactone 25–50 mg, or metolazone 2.5–5 mg) rather than further escalating furosemide alone 2, 1

Transition to Oral Therapy

• Replace IV therapy with oral furosemide as soon as the patient is clinically stable and able to take oral medications, typically after achieving euvolemia 4
• The oral dose should be at least equivalent to the total daily IV dose that achieved adequate diuresis 1
• Continue oral diuretic therapy indefinitely in most heart failure patients, though dose reduction is often possible after achieving dry weight 1

Absolute Contraindications Requiring Immediate Cessation

• Systolic blood pressure <90 mmHg without circulatory support 1
• Severe hyponatremia (serum sodium <120–125 mmol/L) 1
• Anuria (no urine output) 1
• Severe hypokalemia (serum potassium <3.0 mmol/L) 1

Common Pitfalls to Avoid

• Do not continue the infusion beyond 72 hours without reassessing the need for combination diuretic therapy or alternative decongestion strategies 1
• Do not delay transition to oral therapy once euvolemia is achieved, as prolonged IV therapy increases infection risk and healthcare costs without additional benefit 4
• A transient rise in serum creatinine ≤0.3 mg/dL is acceptable in asymptomatic patients; persistent congestion poses greater risk than mild renal dysfunction 1
• Do not use continuous infusion as first-line therapy in stable outpatients; reserve it for hospitalized patients with acute decompensation requiring aggressive diuresis 1, 4

Evidence on Continuous vs. Bolus Dosing

• Continuous infusion may produce 12–26% greater diuresis and 11–33% greater natriuresis compared to intermittent boluses in severe heart failure 5
• However, a randomized trial found no significant difference in creatinine change, urine output, or length of stay between continuous infusion and bolus dosing when equivalent total doses were used 6
• Low-dose continuous infusion (<160 mg/24 hours) was effective in achieving diuresis without detectable effect on renal function in a retrospective study of 150 patients 7