• Prehospital use of furosemide for the treatment of heart failure

    by Alan Batt. Last modified: 18/04/14

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    Summary

    • Retrospective review of health records from EMS system and hospital ED
    • 330 patients included
      • 58 had furosemide given but had no heart failure (HF) diagnosed in ED (false positive)
      • 110 had furosemide given and had a diagnosis of HF in the ED (true positive)
      • 162 had no furosemide given but HF was diagnosed in the ED (false negative)
    • Serious adverse outcomes were identified in
      • 23.6% in the furosemide-HF group
      • 19.0% in the furosemide-no HF group
      • 14.8% in the no furosemide-HF group
    • Of those admitted to hospital, those who received furosemide had a slightly increased length of stay
    • Those to whom furosemide was administered were more likely to have received sublingual nitroglycerin
    • Patients who appeared more acutely ill (based on vital sign review) were more likely to receive furosemide
    • This study reinforces the difficulty in identifying heart failure patients in the prehospital setting – of the 272 cases of heart failure diagnosed on arrival to the ED, Paramedics had only diagnosed 110 and incorrectly diagnosed a further 58. More than 1/3 of patients who received prehospital furosemide did not have an HF diagnosis.
    • However, even with additional diagnostic tools, 8.6% of patients without a final diagnosis of HF in this study received subsequent doses of furosemide in the ED.
    • This study shows the need for a large, randomized-trial to answer the question whether early administration of furosemide in prehospital setting conveys any additional benefits or harms.

    Limitations

    • Retrospective review cannot show temporal relationship (cause-effect)
    • Data was collected by a single abstractor who was not blinded to the outcomes
    • Patients less than 50 years of age, those with a primary presentation other than shortness of breath (eg, chest pain) and subsequent visits by the same patient were excluded from the study

     
    Pan A1, Stiell IG, Dionne R, Maloney J. Prehospital use of furosemide for the treatment of heart failure. Emerg Med J. 2014 Apr 4. PMID: 24705923.

    Abstract

    Background

    The diagnosis and management of acute decompensated heart failure (HF) in the prehospital setting can be challenging. The objectives of this study are to evaluate the appropriateness of furosemide use by Emergency Medical Services (EMS) and its association with adverse outcomes.

    Methods

    This study was a multi-centre health records review of EMS patients who received prehospital furosemide or had an emergency department (ED) diagnosis of HF. We included acutely ill patients ≥50 years of age with shortness of breath transported by land EMS. Univariate and logistic regression analyses were performed to determine associations between furosemide use and serious adverse outcomes (acute renal failure, intubation, vasopressors or death).

    Results

    The study population consisted of 330 patients (N=58, furosemide given by EMS but no HF diagnosed in ED; N=110, furosemide given, HF diagnosed; N=162, no furosemide given, HF diagnosed). The median dose of intravenous furosemide was 80 mg (range 20-80 mg). Serious adverse outcomes occurred in 61 patients (19.0%, 23.6% and 14.8% of the three groups, respectively; p=0.18). The adjusted ORs for adverse events with furosemide use was 0.62 (95% CI 0.33 to 1.43) in patients with a diagnosis of HF and 1.14 (95% CI 0.58 to 2.23) in those without.

    Conclusions

    More than a third of patients who received prehospital furosemide did not have an HF diagnosis, suggesting that the prehospital diagnosis of HF can be challenging. Serious adverse outcomes were identified in all patient groups and we found no statistically significant associations between furosemide use and adverse events.

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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

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