Clinical question: Is simultaneous infusion of hypertonic saline and IV furosemide more efficacious than IV furosemide alone in patients with fluid overload?
Background: Diuretic-resistant fluid overload is a common problem encountered in hospitalized heart failure (HF) patients, with different interventions proposed to overcome it. Some studies have suggested that combining hypertonic saline with furosemide provided advantages over furosemide alone.
Study design: Systematic review and meta-analysis.
Setting: A comprehensive search of several databases from each database’s inception to March 17, 2020, and reference lists of retrieved articles and review articles in the field to identify additional publications.
Synopsis: 11 RCTs met the criteria with a combined 2,987 patients. A random-effects model was used to estimate treatment effects across studies. Results were expressed as either relative risk (RR) for dichotomous outcomes, or mean difference (MD) for continuous. Compared to furosemide alone, hypertonic saline with furosemide was associated with reduced all-cause mortality at 57 months (RR 0.55, P <0.05); reduced HF-related readmissions at 57 months (RR 0.50, P <0.05); reduced hospital length of stay (MD -3.28 days, P <0.05); increased daily diuresis (MD 583.87 mL, P <0.05); increased weight loss (MD-1.76 kg, P <0.05); greater decrease of serum Cr (MD -0.46 mg/dL, P <0.05); greater increase of serum Na (MD 6.89 mEq/L, P <0.05); increased 24-hour urine Na excretion (MD, 61.10 mEq, P <0.05). One limitation is that studies ooliopnly looked at patients with HF with ejection fraction (EF) <40% and without severe renal impairment, limiting generalizability to other fluid-overloaded states or more advanced renal dysfunction. The optimal dose, duration, and concentration of hypertonic saline also remain to be determined.
Bottom line: Simultaneous hypertonic saline solution infusion with intravenous furosemide is a promising approach to managing fluid overloaded patients with HF and reduced EF compared to intravenous furosemide alone.
Citation: Liu, C et al. Simultaneous use of hypertonic saline and IV furosemide for fluid overload. Critical Care Medicine. 2021;49:e1163-e1175.
Dr. Obisesan is an assistant professor in the division of hospital medicine, Emory University School of Medicine, and associate site director at Grady Memorial Hospital, Atlanta