Use of continuous-infusion loop diuretics in critically ill children

Area of Science:

• Pediatric Critical Care Medicine
• Clinical Pharmacology
• Pharmacotherapy

Background:

• Loop diuretics are essential for fluid management in critically ill children, often given as continuous infusions (CI) in hemodynamically unstable patients.
• Recent drug shortages of bumetanide, torsemide, and furosemide necessitate exploring alternative agents for CI.
• Continuous infusion offers potential benefits over intermittent dosing by minimizing hemodynamic fluctuations.

Purpose of the Study:

• To conduct a literature search for studies evaluating continuous intravenous infusion (CI) of loop diuretics (furosemide, bumetanide, ethacrynic acid, torsemide) in critically ill children.
• To identify available evidence on the use and dosing of alternative loop diuretics for CI in pediatric critical care.
• To inform clinical practice regarding the selection and administration of loop diuretics via CI.

Main Methods:

• Systematic literature search of MEDLINE, EMBASE, International Pharmaceutical Abstracts, and Cochrane Database (up to December 2013).
• Inclusion of English-language articles evaluating CI of furosemide, bumetanide, ethacrynic acid, and torsemide in critically ill children.
• Review of reference citations from relevant identified articles.

Main Results:

• Analysis included 10 reports comprising 173 pediatric patients.
• Most evidence focused on furosemide CI; no reports specifically identified for torsemide CI.
• Significant variability in reported CI dosing regimens was observed across studies.

Conclusions:

• Clinicians must consider adverse event profiles, drug compatibility, and pharmacoeconomics when choosing loop diuretics for CI.
• Routine monitoring of fluid balance and urine output is critical to ensure efficacy and guide dosing.
• Initiating therapy with the lowest effective dose is recommended to achieve target urine output (1-3 mL/kg/hour) while minimizing toxicity risk.