The debate about continuous IV Lasix (Furosemide) drips versus IV boluses for treating CHF exacerbation continues. Multiple studies have been done and ‘results’ vary. A meta-analysis of 8 randomized controlled trials was published in 2018 concluded that there was no difference in prognosis, length of hospital stay, or creatinine elevation BUT a continuous drip did achieve significantly higher diuresis volumes in the same time and greater drops in BNP levels.
To me – as a inpatient hospitalist – the parameters of ‘better’ are dictated by my desire for faster & effective diuresis for earlier discharge and keeping costs low. Even if the creatinine elevation risk was deemed similar, in my experience keeping up BP with titrated drip rates & adding Midodrine keeps that risk low (and creatinine bounces back faster once drip is paused ). Even if creatinine goes up, the amount of diuresis I see per unit rise in creatinine is superior compared to a bolus related creatinine elevation.
Secondly, the studies also don’t talk about the cost angle. At any store, buying any item in bulk costs less per item than buying in singles or doubles. The economics of a Lasix drip bag versus giving bolus shots is somewhat similar. At least at my hospital, inpatient cost of administering one Lasix drip bag is similar to an IV bolus, no matter the dose. So a bag of Lasix drip running at say 5-10mg an hour over 24 hours pumps in 120 to 240 mg of Lasix, while a 40mg IV Boluses given twice a day would get in 80-120mg in 2-3 doses over 24 hours but cost 2-3 times more than a drip with less diuresis.
💡 In my experience & opinion, continuous Lasix drip infusion offers more bang (or piss) for the buck 😎. I prefer using Lasix drip without initial boluses, start with 10mg/hour if BP high and lower to 5 mg/hour if BP slides. Add Oral Midodrine 5-10mg TID as needed to raise Systolic BP close to 120 mm Hg to preserve renal perfusion pressures & reduce AKI risk while on the drip. One caveat to remember – use it overnight only if patient has a Foley, otherwise all that pissing & no sleeping will piss them off !
Clinical situations where I especially prefer Lasix drip for diuresis for fluid overload:
– Low blood pressure
– Current AKI or progressive CKD where a more consistent urine flow is better than rapid gushes from Lasix boluses
– Very significant fluid overload
– Patient has a Foley catheter anyway
p.s. : I wish all diuretic orders automatically triggered a reminder for stopping IV fluids in EMR
