Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc
Journal website https://www.jocmr.org

Original Article

Volume 13, Number 4, April 2021, pages 245-251


Outpatient Intravenous Diuretic Clinic: An Effective Strategy for Management of Volume Overload and Reducing Immediate Hospital Admissions

Figure

Figure 1.
Figure 1. Median Weight loss (lb) and interquartile range at day 0, day 2 and day 7. Weight losses at day 2 and day 7 were significantly higher than that at day 0 (P < 0.05 for both comparisons).

Tables

Table 1. Eligibility Criteria for Outpatient IV Diuretic Clinic
 
IV: intravenous; SBP: systolic blood pressure; NYHA: New York Heart Association; Cr: creatinine.
Primary diagnosis of heart failure
Signs and symptoms of acute decompensated heart failure (weight gain, dyspnea)
Symptoms refractory to higher doses of oral diuretics
No acute cardiovascular issue (acute coronary syndrome, new arrhythmia, pulmonary embolism)
SBP > 100 or at baseline SBP
Heart rate 50 - 120
Does not have NYHA class IV symptoms (dyspnea at rest, home inotropes)
Cr ≤ 2.5 or near baseline (increase < 0.5)
O2 saturation ≥ 90% on ≤ 2 L oxygen by nasal cannula or within 2 L baseline oxygen requirement
On ≤ 260 mg lasix daily or 10 mg bumex daily at home
Labs: blood glucose < 400 mg/dL, Na > 120 mmol/L, T bilirubin < 3 mg/dL

 

Table 2. Patient Demographics
 
Values are represented as n (%) or median (interquartile range). HFrEF: heart failure with reduced ejection fraction; ICM: ischemic cardiomyopathy; NYHA: New York Heart Association; Afib: atrial fibrillation; CAD: coronary artery disease; COPD: chronic obstructive lung disease; CKD: chronic kidney disease; DM2: diabetes mellitus type 2; HLD: hyperlipidemia; HTN: hypertension; ACE-I: angiotensin-converting enzyme inhibitor; ARB: angiotensin II receptor blocker; BB: beta-blocker; MRA: mineralocorticoid receptor antagonist; ICD: implantable cardioverter defibrillator; CRT-D: cardiac resynchronization therapy defibrillator.
Age72 (67 - 80)
Male25 (93)
Weight, lb238 (189 - 275)
HFrEF14 (52)
ICM13 (48)
Comorbidities
  Afib15 (56)
  CAD13 (48)
  COPD8 (30)
  CKD 3 or above23 (85)
  DM218 (67)
  HLD14 (52)
  HTN18 (67)
Loop diuretic
  Furosemide8 (30)
  Bumetanide18 (67)
  Torsemide1 (4)
  Total loop diuretic dose (oral furosemide equivalent), mg160 (120 - 240)
  Thiazide diuretic14 (52)
HFrEF (14)HFpEF (13)
ACE-I or ARB4 (29)5 (38)
Sacubitril-Valsartan2 (14)0(0)
BB12 (86)10 (77)
MRA8 (57)8 (62)
Isosorbide0 (0)1 (8)
Hydralazine0 (0)0 (0)
Digoxin1 (7)0 (0)
Devices
  ICD only1 (8)0 (0)
  CRT-D7 (50)0 (0)
  CardioMEMS2 (14)1 (8)

 

Table 3. Visit Metrics
 
Before IV diuresisAfter IV diuresis
Values are represented as median (interquartile range). IV: intravenous; BUN: blood urea nitrogen; BNP: brain natriuretic peptide.
Lab
  Serum sodium, mmol/L138 (136 - 139)138 (136 - 140)
  Serum potassium, mmol/L4 (3.5 - 4.5)3.9 (3.4 - 4.3)
  Serum creatinine, mg/dL1.59 (1.27 - 1.82)1.55 (1.25 - 1.95)
  Serum BUN, mg/dL33.5 (24.8 - 51.2)33 (23 - 49)
  BNP, pg/mL597 (145 - 1,466)-
Hemodynamics
  Systolic blood pressure, mm Hg111 (101.5 - 127.5)116 (108 - 125)
  Diastolic blood pressure, mm Hg67 (58 - 75)68 (62 - 76)
  Heart rate78 (75 - 82)79 (72 - 82)
Clinic outcomes
  Urine output, mL1,500 (1,030 - 2,600)
  Weight loss, lb2.8 (1.7 - 3.9)

 

Table 4. Outcomes for HFrEF and HFpEF Groups
 
OutcomesHFrEF* (N = 14)HFpEF* (N = 13)P value
*Values are expressed as median (interquartile range). HFpEF: heart failure with preserved ejection fraction; HFrEF: heart failure with reduced ejection fraction.
Urine output, mL1,350 (935 - 1,900)1,686 (1,362 - 2,637)0.25
Weight loss, lb
  Day 02.6 (1.6 - 3.7)2.8 (1.9 - 4.4)0.65
  Day 27.1 (3.2 - 11.4)5.4 (3.8 - 7.9)0.53
  Day 76.7 (1.5 - 10.9)4.6 (2.3 - 8.4)0.51

 

Table 5. Cost Data
 
*Values are expressed as median (interquartile range).
Clinic visit*$1,076 (960 - 1,233)
Hospital admission*$11,471 (4,818 - 26,880)
Hospital admission per day*$1,912 (535 - 2,987)
Estimated cost saving (per admission prevented)$10,395

 

Table 6. Safety Outcomes
 
Values are represented as n (%). AKI is defined as increase in Cr by 0.3 mg/dL. Severe hypokalemia is defined as potassium < 3.0 mmol/L and mild-moderate hypokalemia as 3.0 - 3.5 mmol/L. AKI: acute kidney injury.
Arrhythmia0
AKI0
Hypotension0
Severe hypokalemia1 (3)
Mild-moderate hypokalemia22 (65)
Same-day admission1