Table 2.

Final recommendations on loop diuretic use in critically ill patients

Recommendation	Details
Individualized dosing	Tailor dosing based on patient-specific factors (e.g., organ function, fluid balance, and comorbidities) rather than relying on stereotypical regimens. To optimize dose–response while minimizing risk of toxicity, a ceiling furosemide dose of 6 mg/kg/day is usually desired
Threshold identification	Carefully identify the minimum effective dose needed to surpass the natriuretic threshold, especially in resistant patients. To optimize dose–response while minimizing risk of toxicity, a ceiling furosemide dose of 6 mg/kg/day is usually desired
Use of combination therapy	Combine loop diuretics with thiazides or other classes in resistant cases to overcome the braking phenomenon
Continuous vs. bolus infusion	Continuous infusion may offer more stable diuretic response and fewer fluctuations; however, evidence for mortality benefit is lacking
Albumin co-administration	Consider albumin only in hypoalbuminemic patients, particularly those with nephrotic syndrome; avoid routine use
Monitor for resistance	Regularly assess response via urine output and fluid balance; escalate therapy when resistance is observed
Caution in hypoalbuminemia and kidney dysfunction	Adjust dose and route (prefer i.v.) to compensate for reduced drug delivery and bioavailability
No clear superiority between loop diuretics	Furosemide remains first-line owing to familiarity; ethacrynic acid may be used when sulfa allergy is suspected, but it is less potent