What’s the evidence behind different dosing strategies of diuretics in patients with decompensated heart failure?
Diuretic Strategies in Patients with Acute Decompensated Heart Failure (DOSE)
Felker G et al. NEJM (March 2011)
Bottom line: This was a prospective, double-blind, randomized trial with a sample size of 308 patients with acute decompensated heart failure. Patients were assigned to receive furosemide intravenously through either a bolus every 12 hours or continuous infusion at a low dose (equivalent to the patient’s previous oral dose) or high dose (2.5 times the previous oral dose). The primary outcomes were patients’ global assessment of symptoms and change in serum creatinine level over 72 hours. There were no significant differences in these outcomes between the different administration methods or dosages. The high-dose strategy was associated with greater diuresis and some secondary measures, but also with transient worsening of renal function. Overall, outcomes were comparable between the intervention and control groups.
What’s the rationale for giving magnesium to prevent eclampsia?
Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial
The Magpie Trial Collaborative Group. The Lancet (June 2002)
Bottom Line: This randomized clinical trial evaluated the use of magnesium sulphate in preventing eclamptic convulsions and improving outcomes in pregnant patients with pre-eclampsia. Eligible patients had not given birth or were 24 h or less postpartum; had a blood pressure of 140/90 mmHg or more, and proteinuria of 1+ (30 mg/dL) or more; and clinical uncertainty about magnesium sulphate. A total of 10,141 study participants were randomized to receive either magnesium sulphate or placebo. The primary outcomes were eclampsia and fetal demise for patients randomized before delivery. Results showed that those in the magnesium sulphate group had a 58% lower risk of eclampsia (95% CI 40–71) and a lower risk of maternal mortality compared to those in the placebo group (relative risk 0.55, 0.26–1.14). There were no significant harmful effects observed in the short term and no clear difference in the risk of fetal demise (576, 12.7%, vs 558, 12.4%; relative risk 1.02, 99% CI 0.92–1.14). The only notable difference in morbidity was for placental abruption (relative risk 0.67, 99% CI 0.45–0.89). This study provides evidence for the effectiveness of magnesium sulphate in reducing the risk of eclampsia and maternal death in patients with pre-eclampsia.
Why should I consider prone positioning for my patient with acute respiratory distress syndrome (ARDS)?
Prone Positioning in Severe Acute Respiratory Distress Syndrome (PROSEVA)
Guérin C et al. NEJM (June 2013)
Bottom Line: This multicenter, prospective, randomized, controlled trial evaluated the effect of early application of prone positioning on outcomes in patients with severe ARDS. Severe ARDS was defined as a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (FiO2) of less than 150 mm Hg, with an FiO2 of at least 0.6, a positive end-expiratory pressure of at least 5 cm of water, and a tidal volume close to 6 ml per kilogram of predicted body weight. A total of 466 patients were randomly assigned to undergo prone-positioning sessions of at least 16 hours or to be left in the supine position. The primary outcome was 28-day mortality, which was significantly lower in the prone group compared to the supine group (16.0% vs 32.8%, respectively). The hazard ratio for death with prone positioning was 0.39 (95% CI, 0.25 to 0.63). The incidence of complications did not differ significantly between the groups, except for a higher incidence of cardiac arrests in the supine group. The conclusion of this study was that early application of prolonged prone-positioning sessions significantly decreased 28-day and 90-day mortality in patients with severe ARDS.
