Table 3.
Stepped diuretic strategy: Treatment algorithm from CARRESS-HF
| Daily UO assessment | ||
| UO > 5 L/day : reduce current diuretic regimen if desired | ||
| UO3–5 L/day : continue current diuretic regimen | ||
| UO < 3 L/ day : see diuretic table | ||
| At 24 hours assessment | ||
| If persistent volume overload | ||
| Assessed daily UO as above | ||
| Advance to the next step on diuretic table if UO < 3 L/ day | ||
| At 48 hours assessment | ||
| If persistent volume overload | ||
| Assessed daily UO as above | ||
| Advance to the next step on diuretic table if UO < 3 L/ day and consider | ||
| : Dobutamine or dopamine at 2 μg/kg/min if SBP < 100 mmHg and LVEF < 40% or | ||
| RV systolic dysfunction | ||
| : Nitroglycerin or nesiritide if SBP > 120 mmHg and severe symptoms | ||
| At 72–96 hours assessment | ||
| If persistent volume overload | ||
| Assessed daily UO as above | ||
| Advance to the next step on diuretic table if UO < 3L/ day and consider | ||
| : Dobutamine or dopamine at 2 μg/kg/min if SBP < 100 mmHg and LVEF < 40% or | ||
| RV systolic dysfunction | ||
| : Nitroglycerin or nesiritide if SBP > 120 mmHg and severe symptoms | ||
| - Hemodynamic guided IV-therapy | ||
| - LVAD | ||
| - UF or dialysis | ||
| Diuretic table | ||
| Current loop diuretic | Suggested dose | |
| dose | Loop diuretic dose | Thiazide dose |
| ± thiazide | ||
| A. ≤80 mg | 40 mg IV bolus + 5 mg/hr | 0 |
| B. 81–160 mg | 80 mg Iv bolus + 10 mg/hr | 5 mg metolazone QD |
| C. 161–240 mg | 80 mg Iv bolus + 20 mg/hr | 5 mg metolazone BID |
| D. ≥240 mg | 80 mg Iv bolus + 30 mg/hr | 5 mg metolazone BID |
CARRESS-HF: Cardiorenal Rescue Study in Acute Decompensated Heart Failure, UO: Urine output, LVEF: Left ventricular ejection fraction, RV: Right ventricle, SBP: Systolic blood pressure, LVAD: Left ventricular assist device, UF: Ultrafiltration (From https://biolincc.nhlbi.nih.gov/media/studies/carress/Protocol.pdf?link_time=2020-01-15_23:30:43.304569.)