Intravenous furosemide in decompensated heart failure: do not protocolize dosing but the desired effect!

Palazzuoli and colleagues report on a study comparing continuous versus bolus infusion of furosemide in acute decompensated heart failure [1]. Patients in the continuous infusion group had greater urine output, decreased renal function and increased 6-month mortality. We feel that, due to the study design, the conclusions drawn are difficult to translate into clinical practice. The decisive advantage of continuous over bolus infusion is the ability to titrate to effect in a gradual and precise manner. This advantage is completely negated when large-step (that is, doubling) dose increases are rigidly protocolized, as was the case in this study. When the advantages of a method are lost, only its comparative harms remain: continuous infusion may have a stronger diuretic effect than bolus infusion (milligram for milligram) [2] and the continuous