J Clin Med Res

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 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).

**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 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.
Age	72 (67 - 80)
Male	25 (93)
Weight, lb	238 (189 - 275)
HFrEF	14 (52)
ICM	13 (48)
Comorbidities
Afib	15 (56)
CAD	13 (48)
COPD	8 (30)
CKD 3 or above	23 (85)
DM2	18 (67)
HLD	14 (52)
HTN	18 (67)
Loop diuretic
Furosemide	8 (30)
Bumetanide	18 (67)
Torsemide	1 (4)
Total loop diuretic dose (oral furosemide equivalent), mg	160 (120 - 240)
Thiazide diuretic	14 (52)
	HFrEF (14)	HFpEF (13)
ACE-I or ARB	4 (29)	5 (38)
Sacubitril-Valsartan	2 (14)	0(0)
BB	12 (86)	10 (77)
MRA	8 (57)	8 (62)
Isosorbide	0 (0)	1 (8)
Hydralazine	0 (0)	0 (0)
Digoxin	1 (7)	0 (0)
Devices
ICD only	1 (8)	0 (0)
CRT-D	7 (50)	0 (0)
CardioMEMS	2 (14)	1 (8)

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.

Age

72 (67 - 80)

Male

25 (93)

Weight, lb

238 (189 - 275)

HFrEF

14 (52)

ICM

13 (48)

Comorbidities

Afib

15 (56)

CAD

13 (48)

COPD

8 (30)

CKD 3 or above

23 (85)

DM2

18 (67)

HLD

14 (52)

HTN

18 (67)

Loop diuretic

Furosemide

8 (30)

Bumetanide

18 (67)

Torsemide

1 (4)

Total loop diuretic dose (oral furosemide equivalent), mg

160 (120 - 240)

Thiazide diuretic

14 (52)

HFrEF (14)

HFpEF (13)

ACE-I or ARB

4 (29)

5 (38)

Sacubitril-Valsartan

2 (14)

0(0)

12 (86)

10 (77)

MRA

8 (57)

8 (62)

Isosorbide

0 (0)

1 (8)

Hydralazine

0 (0)

Digoxin

1 (7)

0 (0)

Devices

ICD only

1 (8)

0 (0)

CRT-D

7 (50)

0 (0)

CardioMEMS

2 (14)

1 (8)

**Table 3.** Visit Metrics
	Before IV diuresis	After IV diuresis
Values are represented as median (interquartile range). IV: intravenous; BUN: blood urea nitrogen; BNP: brain natriuretic peptide.
Lab
Serum sodium, mmol/L	138 (136 - 139)	138 (136 - 140)
Serum potassium, mmol/L	4 (3.5 - 4.5)	3.9 (3.4 - 4.3)
Serum creatinine, mg/dL	1.59 (1.27 - 1.82)	1.55 (1.25 - 1.95)
Serum BUN, mg/dL	33.5 (24.8 - 51.2)	33 (23 - 49)
BNP, pg/mL	597 (145 - 1,466)	-
Hemodynamics
Systolic blood pressure, mm Hg	111 (101.5 - 127.5)	116 (108 - 125)
Diastolic blood pressure, mm Hg	67 (58 - 75)	68 (62 - 76)
Heart rate	78 (75 - 82)	79 (72 - 82)
Clinic outcomes
Urine output, mL	1,500 (1,030 - 2,600)
Weight loss, lb	2.8 (1.7 - 3.9)

Table 3. Visit Metrics

Before IV diuresis

After IV diuresis

Values are represented as median (interquartile range). IV: intravenous; BUN: blood urea nitrogen; BNP: brain natriuretic peptide.

Lab

Serum sodium, mmol/L

138 (136 - 139)

138 (136 - 140)

Serum potassium, mmol/L

4 (3.5 - 4.5)

3.9 (3.4 - 4.3)

Serum creatinine, mg/dL

1.59 (1.27 - 1.82)

1.55 (1.25 - 1.95)

Serum BUN, mg/dL

33.5 (24.8 - 51.2)

33 (23 - 49)

BNP, pg/mL

597 (145 - 1,466)

Hemodynamics

Systolic blood pressure, mm Hg

111 (101.5 - 127.5)

116 (108 - 125)

Diastolic blood pressure, mm Hg

67 (58 - 75)

68 (62 - 76)

Heart rate

78 (75 - 82)

79 (72 - 82)

Clinic outcomes

Urine output, mL

1,500 (1,030 - 2,600)

Weight loss, lb

2.8 (1.7 - 3.9)

**Table 4.** Outcomes for HFrEF and HFpEF Groups
Outcomes	HFrEF* (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, mL	1,350 (935 - 1,900)	1,686 (1,362 - 2,637)	0.25
Weight loss, lb
Day 0	2.6 (1.6 - 3.7)	2.8 (1.9 - 4.4)	0.65
Day 2	7.1 (3.2 - 11.4)	5.4 (3.8 - 7.9)	0.53
Day 7	6.7 (1.5 - 10.9)	4.6 (2.3 - 8.4)	0.51

Table 4. Outcomes for HFrEF and HFpEF Groups

Outcomes

HFrEF* (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, mL

1,350 (935 - 1,900)

1,686 (1,362 - 2,637)

0.25

Weight loss, lb

Day 0

2.6 (1.6 - 3.7)

2.8 (1.9 - 4.4)

0.65

Day 2

7.1 (3.2 - 11.4)

5.4 (3.8 - 7.9)

0.53

Day 7

6.7 (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 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.
Arrhythmia	0
AKI	0
Hypotension	0
Severe hypokalemia	1 (3)
Mild-moderate hypokalemia	22 (65)
Same-day admission	1

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.

Arrhythmia

AKI

Hypotension

Severe hypokalemia

1 (3)

Mild-moderate hypokalemia

22 (65)

Same-day admission