Albumin Diuretic in Hipoalbumin

7/27/2019 Albumin Diuretic in Hipoalbumin

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Notice to CNE enrollees:A closed-book, multiple-choice examinationfollowing this article tests your understanding ofthe following objectives:

1. Examine the effect of albumin on the diureticeffect of furosemide.

2. Correlate findings of various studies related to

the sequential administration of albumin andfurosemide.

3. Identify study limitations and opportunitiesfor future research related to administration offurosemide and albumin.

To read this article and take the test online,visit www.ajcconline.org and click CNE Arti-cles in This Issue. No fee for AACN members.

By Thitima Doungngern, PharmD, BCPS,Yvonne Huckleberry, PharmD, BCPS,John W. Bloom, MD, and Brian Erstad, PharmD.

Background Albumin is broadly prescribed for critically ill

patients although it does not have a mortality benefit over

crystalloids. One common use of albumin is to promote diuresis.

Objectives To compare urine output in patients treated withfurosemide with and without albumin and to assess other

variables possibly associated with enhanced diuresis.

Methods A retrospective study was conducted on patients in

a medical intensive care unit who received furosemide therapy

as a continuous infusion with and without 25% albumin for

more than 6 hours. Primary end points were urine output and

net fluid loss.

Results A total of 31 patients were included in the final analysis.

Mean urine output in patients treated with furosemide alone did

not differ significantly from output in patients treated with furo-

semide plus albumin at 6, 24, and 48 hours: mean output, 1119

(SD, 597) mL vs 1201 (SD, 612) mL, P= .56; 4323 (SD, 1717) mL

vs 4615 (SD, 1741) mL, P= .42; and 7563 mL (SD, 2766) vs 7432(SD, 2324) mL, P= .94, respectively. Additionally, net fluid loss

did not differ significantly between the 2 groups at 6, 24, and

48 hours. Higher concentrations of serum albumin did not

improve urine output. The only independent variable signifi-

cantly associated with enhanced urine output at 24 and 48

hours was increased fluid intake.

Conclusion Addition of albumin to a furosemide infusion did

not enhance diuresis obtained with furosemide alone in criti-

cally ill patients. (American Journal of Critical Care. 2012;21:

280-286)

EFFECT OFALBUMIN ONDIURETIC RESPONSE TOFUROSEMIDE IN PATIENTS

WITH HYPOALBUMINEMIA

280 AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2012, Volume 21, No. 4 www.ajcconline.org

2012 American Association of Critical-Care Nursesdoi: http://dx.doi.org/10.4037/ajcc2012999

Pharmacology in Critical Care


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The mechanism of diuretic resistance remains

unclear, but hypoalbuminemia may be one of the

causes.2A preliminary study by Inoue et al3 indicated

that the combination of furosemide and albumin,

given as a single bolus, was as effective as the same

dose of furosemide alone in improving urine output

in patients with diuretic resistance. Maximal urine

output occurred within 1 hour in both groups of

patients. Patients had various diagnoses, and theclinical design of the study3 is not well described.

In subsequent studies4-8with improved designs, the

effects of furosemide plus albumin in specific popu-

lations of patients such as those with nephrotic syn-

drome and cirrhosis with ascites were conflicting.

Most recently, Martin et al9 suggested that furosemide

plus albumin may be better than furosemide alone

for the treatment of adult respiratory distress syn-

drome. Because of the large number of patients

needed to show potential mortality differences with

the use of albumin, investigators have focused on

more specific benefits of albumin related to oxy-

genation or diuresis.

Because of periodic shortages, high cost, and

potential adverse effects of albumin, studies of the

effectiveness of albumin in enhancing diuresis in

critically ill patients are needed.10 Our study was

designed to determine if continuous infusions of

25% albumin enhanced urine output when given

with continuous infusions of furosemide. We had

a unique opportunity to study this issue because

cotherapy with albumin and furosemide infusions

that may precede or follow furosemide infusions

alone are often used in the medical intensive care

unit (ICU) at Arizona Health Sciences Center, Tuc-

son, Arizona. The primary objective of the study was

to compare urine output in patients given furosemide

alone with output in patients given both furosemide

and albumin. The secondary objective was to iden-tify other variables that might be associated with

enhanced diuresis.

MethodsStudy Design

Adult patients in the medical ICU who received

a continuous furosemide infusion with and without

25% albumin were studied retro-

spectively. The study was conducted

at Arizona Health Sciences Center, a

tertiary care, academic medical cen-

ter. The local institutional review

board reviewed and approved the

study. Primary end points were

urine output and net fluid loss.

The diuretic effect of a continu-

ous infusion of furosemide peaks

approximately 3 hours after the

infusion is started.3Therefore,

cumulative urine output at 6 hours

was chosen as the initial and primary end point to

ensure measurement of the full diuretic effect of the

furosemide infusion.

Selection of PatientsAny adult patient admitted to the medical ICU

between January 1, 2007, and August 31, 2010, who

received a sequential continuous furosemide infusion

for at least 6 hours and a combined furosemide

plus 25% albumin infusion for at least 6 hours was

included in the study. The order of infusion did not

matter so long as no gap occurred between the 2

sequential infusions. Patients were excluded if they

did not have sequential infusions of furosemide

V

olume overload, a common problem in critically ill patients, is typically treated with

fluid restriction and diuretics. Furosemide is the loop diuretic most often prescribed

to enhance urine output in these patients. Compared with bolus administration,

continuous infusion of furosemide may improve diuresis with fewer adverse effects.1,2

However, furosemide resistance may occur in critically ill patients despite alterations

in dosing regimens, making it difficult to achieve goals for fluid output. 2

About the AuthorsThitima Doungngern is a member of the faculty of phar-

maceutical sciences at Prince of Songkla University,Hat Yai, Songkhla, Thailand. At the time of the study,Doungngern was a specialized resident in internal medi-cine. Yvonne Huckleberry is a critical care pharmacist,University of Arizona Medical Center, John W. Bloom isan associate professor, Departments of Pharmacologyand Medicine, College of Medicine, and Brian Erstad isa professor, College of Pharmacy, at the University ofArizona, Tucson, Arizona.

Corresponding author: Brian Erstad, PharmD, Professor,College of Pharmacy, University of Arizona, 1703E Mabel St, Tucson, Arizona, 85721 (e-mail: [email protected]).

www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2012, Volume 21, No. 4 281

Compared with

bolus, continuous

infusion offurosemide may

improve diuresis

with fewer

adverse effects.


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t test was used to evaluate unpaired data. Linear

regression analysis was used to investigate relation-

ships between the dependent variable urine output

and demographic independent variables (age, weight,

severity of illness) and other independent variables

(ie, furosemide or albumin dose, fluid intake, and

serum albumin concentrations) at 24 and 48 hoursfor both groups of patients. Significance was defined

as P< .05 unless otherwise noted (Bonferroni cor-

rection for post hoc testing). All data are reported

as mean and standard deviation.

ResultsA total of 170 patients received continuous

infusions of furosemide and 25% albumin during

the study period. Thirty-six of these patients met the

inclusion criteria of receiving continuous infusions

of furosemide with and without 25% albumin for

at least 6 hours. Of these, 5 patients had serum cre-atinine levels greater than 1.5 mg/dL and/or acute

tubular necrosis. Therefore, data on 31 patients were

included in the final analysis. Of the 31 patients, 17

initially received furosemide infusions; the other 14

patients initially received infusions of furosemide

plus albumin.

A total of 19 patients (61%) were women, and

the mean age was 54.3 years. The 3 most common

underlying illnesses were cancer (36%), most often

skin cancer; cardiovascular disease (23%); and liver

disease (16%), mostly due to hepatitis C. A total of

26 patients (84%) had a ratio of PaO2

to fraction of

inspired air less than 300. Other baseline character-

istics are presented in Table 1.

Table 2 shows data for the patients who received

furosemide alone and furosemide plus albumin.

The infusion rate for furosemide was initiated at 2

to 5 mg/h and titrated in an attempt to achieve a

urine output 50 to 100 mL/h greater than fluid

intake. The infusion rate for 25% albumin was 8 or

10 mL/h in all but 3 patients (rates of 5 mL/h for 2

patients and 12 mL/h for 1 patient). The median

initial furosemide dose was 4 mg/h in patients who

received furosemide alone and 5 mg/h in patients

who received furosemide plus albumin. Differencesin furosemide dose between the 2 groups at 6 hours

(P= .33) and 24 hours (P= .50) were not significant.

At 48 hours, the patients who received furosemide

plus albumin received more furosemide than did the

patients who received furosemide alone (P= .04).

Urine output did not differ significantly between

the 2 groups at 6, 24, or 48 hours (Pvalues: .56, .42,

and .94, respectively). Similarly, urine output did

not differ significantly within the furosemide-alone

group (P= .09) and the furosemide-plus-albumin

and furosemide plus albumin, received furosemide

or furosemide plus albumin before the sequentialinfusions, had incomplete intake and output records,

or had renal dysfunction (defined as serum creatinine

level greater than 1.5 mg/dL; to convert to micromoles

per liter, multiply by 88.4), or any current renal dis-

ease (eg, acute tubular necrosis, glomerulonephritis).

Data Collection

Baseline data collected included age, sex, height,

weight, serum level of creatinine, serum level of

albumin, diuretic medications, ICU diagnosis and

underlying illnesses, ratio of PaO2 to fraction of

inspired oxygen, and scores on the Acute Physiol-

ogy and Chronic Health Evaluation II and the

Sequential Organ Failure Assessment. In addition,

daily measurements of serum levels

of albumin, furosemide and albumin

dosing, fluid intake, and urine output

at the first 6 hours (0-6 hours), and

every 6 hours up to 48 hours (if data

were available) in each group were

recorded.

Statistics

On the basis of data on urine

output in critically ill medical patients,it was estimated that 22 patients

would be needed to detect a 30%

difference in urine output between the furosemide-

alone and the albumin-plus-furosemide groups with

80% power and = .05. However, it was decided to

enroll at least 30 patients to decrease the risk of a

type II error.

Continuous data for comparison of the 2 groups

of patients were evaluated by using paired t tests or

repeated-measures analysis of variance. A 2-sample


At 48 hours,

those receiving

furosemide/albu-

min received more

furosemide than

hose who received

furosemide alone.

Table 1

Baseline characteristics (N = 31)

Characteristic Mean (SD) Range

Abbreviations: APACHE, Acute Physiology and Chronic Health Evaluation; SOFA,Sequential Organ Failure Assessment.

a Day 0, the day that continuous furosemide infusion alone was started. To convertcreatinine level to micromoles per liter, multiply by 88.4.

Age, y

Weight at admission, kg

Height, cm

Serum creatinine, mg/dLa

Serum albumin, g/dLa

APACHE II scorea

SOFA scorea

Ratio of PaO2 to fraction ofinspired oxygena

21-84

46.5-142

148-188

0.5-1.5

1.3-3.2

13-31

2-12

80-465

54.3 (17.8)

78.2 (24.3)

167.2 (10.1)

0.8 (0.3)

2.1 (0.5)

20.6 (5)

7.6 (2.5)

174 (103.9)


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group (P= .89) according to the order in which the

infusions were administered as the primary end

point. Additionally, net fluid loss did not differ sig-

nificantly between the 2 groups at 6, 24, or 48

hours (Pvalues: .42, .47, and .82, respectively).

Table 3 shows the relationship between urine

output and independent variables according to sim-ple regression analysis. Fluid intake was the only

significant predictor of increased urine output for

both the furosemide-alone group (P=.02; R2 = 0.27)

and the furosemide-plus-albumin group (P=.004;

R2 = 0.29) at 24 and 48 hours. In the patients given

furosemide plus albumin, serum levels of albumin

increased from 6 to 24 hours (mean, 2.0 g/dL [SD,

0.46] to 2.4 g/dL [SD, 0.47]; P= .04) and from 24 to

48 hours (mean, 2.4 g/dL [SD, 0.47] to 2.8 g/dL

[SD, 0.45] P= .02), but only the 6 to 48 hour increase

(mean, 2.0 g/dL [SD, 0.46] to 2.8 g/dL [SD, 0.45];

P< .001) was significant with post hoc adjustment

ofPvalues.

DiscussionThis study is the first one done to determine

whether or not continuous infusion of 25% albumin

enhances furosemide-induced diuresis in critically

ill patients. We found that the effect of coadminis-

tration of furosemide and albumin was no greater

than that of continuous infusion of furosemide alone.

Various beneficial mechanisms of the action of

albumin beyond simple volume expansion have been

described. For example, an early evaluation3 of furo-

semide mixed with an equimolar solution of albu-

min in analbuminemic rats suggested that albumin

might play an important role in delivering furo-

semide to its site of action in the kidneys, thereby

enhancing diuresis. In contrast, in a study4 in rats

with nephrotic syndrome, the response to furosemide

was compromised when the drug was given with

albumin, suggesting that furosemide binding to

albumin reduced the availability of the active com-

pound. When medications were added that displaced

furosemide from its albumin binding site, an

improved diuretic response occurred. These conclu-

sions suggest that the relationship between albumin

and furosemide is not well understood.

The method of administration may influence

the efficacy of albumin for diuresis. For example,

results in normal and analbuminemic rats suggest

that albumin and furosemide administered together

form a complex that carries the furosemide to the

kidney for uptake by renal tubular cells. Our study

is the first to investigate the diuretic effects of a con-

tinuous infusion of albumin in medical ICU patients.

In previous studies focused on specific populations

of patients to whom albumin was administered via


Table 2

Continuous data for the furosemide andcombined albumin plus furosemide groupsa

43 (42)

148 (120)

265 (246)a

937 (441)

3136 (1114)

6072 (2814)

1119 (597)

4323 (1717)

7563 (2766)

-181 (646)

-1187 (1594)

-1491 (2711)

52 (43)

165 (77)

420 (231)b

56.6 (8.5)

237 (22)

442 (53)

905 (383)

3694 (1459)

6276 (2635)

1201 (612)

4615 (1741)

7432 (2324)

-295 (571)

-921 (1194)

-1156 (3299)

a All values are mean (SD).b P= .04 for the furosemide dose at 48 hours; all other comparisons were not significantly different.

Time, h

Furosemide alone Furosemide plus albumin

Net fluidloss, mL

Urineoutput, mL

Fluidintake, mL

Albumindose, mL

Furosemidedose, mg

Net fluidloss, mL

Urineoutput, mL

Fluidintake, mL

Furosemidedose, mg

0-6 (N=31)

0-24 (n= 15)

0-48 (n =5)

Table 3

Simple regression analysis of independentvariables with urine output at 24 or 48 hours

Variable P (R2 if significant)

Abbreviations: APACHE, Acute Physiology and Chronic Health Evaluation; SOFA,Sequential Organ Failure Assessment.

Age (24 hours)

Weight in kilograms (24 hours)

APACHE II score (24 hours)

SOFA score (24 hours)

Furosemide dose in furosemide-alone group (24 hours)

Furosemide dose in furosemide-alone group (48 hours)

Furosemide dose in combined albumin group (24 hours)

Furosemide dose in combined albumin group (48 hours)

Albumin dose in combined albumin group (24 hours)

Albumin dose in combined albumin group (48 hours)

Albumin concentration in albumin group (24 hours)

Albumin concentration in albumin group (48 hours)

Fluid intake in furosemide-alone group (24 hours)

Fluid intake in furosemide-alone group (48 hours)

Fluid intake in combined albumin group (24 hours)

Fluid intake in combined albumin group (48 hours)

.14

.22

.44

.94

.77

.047 (0.37)

.35

.23

.36

.48

.90

.047 (0.34)

.02 (0.27)

.02 (0.45)

.004 (0.29)

.03 (0.37)


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coadministration of furosemide and albumin does

not improve diuresis in patients with cirrhosis with

ascites and most likely does not enhance diuresis in

other populations of patients.

Martin et al9 studied furosemide plus albumin

in patients with hypoproteinemia and acute lung

injury treated with mechanical ventilation. In thisrandomized, double-blind, placebo-controlled,

multicentered trial, change in oxygenation over 24

hours was the primary end point. Net fluid loss was

a secondary outcome. A total of 40 patients received

furosemide with either a placebo or albumin. The

control group received a furosemide bolus of 20 mg

followed by a titrated infusion of up to 10 mg/h of

furosemide for 72 hours with a normal saline

placebo substituted for an equivalent volume of

albumin. The treatment group received 25 g of 25%

albumin immediately before the furosemide bolus

and every 8 hours thereafter for the same duration.The improvement in oxygenation and net negative

fluid balance in patients who received furosemide

plus albumin was significantly greater than the

changes in patients given furosemide plus placebo.

These data are the most compelling to date that

suggest albumin may enhance the effectiveness of

furosemide in a specific population of patients.

Although a large percentage of our patients had

a ratio of PaO2 to fraction of inspired oxygen less

than 300, we did not observe a beneficial diuretic

effect with the addition of albumin. One difference

in design between our study and that of Martin et

al9 is that we used continuous infusions of albumin

rather than boluses. Also, we cannot exclude a rela-

tionship between increasing albumin concentrations

and increased diuretic response. This possibility

might account for the net fluid loss noted at 72

hours in the study by Martin et al.

In our regression analysis, albumin concentra-

tion at 48 hours was associated with urine output,

but this finding was based on data from only 5

patients. Furthermore, by 48 hours, significantly

more furosemide had been administered to patients

receiving furosemide plus albumin than to patients

given furosemide alone, a situation that could alsoexplain the increased urine output at this time. In

our study, the one consistent factor significantly

related to increased urine output was increased

fluid intake.

Although hyperoncotic albumin may have

potential benefits in specific populations of

patients, we conclude that the addition of a 25%

albumin infusion to continuous infusion with

furosemide does not improve diuresis in critically

ill patients with hypoalbuminemia. In agreement

intermittent boluses or short-term infusions, the

results were conflicting. In a trial of 8 patients with

nephrotic syndrome, Akcicek et al5 administered

furosemide as a 60-mg intravenous bolus followed

by a 4-hour intravenous infusion of furosemide

with and without 20% albumin. Maximal diuretic

and natriuretic responses occurredduring the drug infusions for all

groups. The addition of albumin had

no diuretic benefit. In contrast, Fliser

et al6 conducted a randomized, dou-

ble-blind, placebo, controlled trial in

9 patients with nephrotic syndrome.

Patients received a 60-mg furosemide

bolus plus placebo, a 60-mg furo-

semide bolus plus 200 mL of 20%

albumin, or placebo given as a bolus plus 200 mL

of 20% albumin. The increase in urine output

between the 3 groups during the 8-hour monitoringperiod were significant. Fliser et al noted that the

same result could possibly be achieved by optimiz-

ing the dose of furosemide alone rather than by

adding albumin.

The combination of furosemide plus albumin

for the management of ascites in patients with cir-

rhosis has also had conflicting results. Gentilini et

al7 performed a randomized, controlled trial of 126

patients with cirrhosis and ascites. Patients were

randomized to receive escalating doses of diuretics

with or without 25% albumin. End points of the

inpatient phase of the trial included disappearance

of ascites and duration of hospital stay. The benefits

of furosemide plus albumin were significantly bet-

ter than the benefits of furosemide alone for both

end points. In contrast to these findings, Chalasani

et al8 found a lack of benefit with

furosemide plus albumin. They per-

formed a randomized crossover

study in 13 patients with cirrhosis

and ascites to evaluate the effects of

albumin on the response to furosemide

as indicated by urinary excretion of

sodium and urine volume. Patients

received each of the following intra-venously over 30 minutes: 40 mg of

furosemide alone, 25 g of albumin

alone, 40 mg of furosemide mixed

with 25 g of albumin, and 40 mg of

furosemide and 25 g of albumin infused simultane-

ously in different arms. Urine output for furosemide

alone was similar to that for either combination.

The diuretic and natriuretic responses returned to

normal within 6 hours of drug administration in all

arms of the study. Chalasani et al8 concluded that


The one consis-

tent factor signifi-

cantly related to

increased urine

output wasincreased fluid

intake.

The method of

administration

may influence the

efficacy of albu-

min for diuresis.


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with previous studies, we recommend optimizing

the furosemide dosing before considering the addi-

tion of colloid. Furthermore, if diuretic resistance

occurs, the addition of a thiazide diuretic may pro-

duce a better result and be more cost-effective in

achieving diuresis in patients with volume overload

whose hemodynamic status is stable.2

Our study had some limitations. Because the

study was retrospective, incorrectly recorded infor-

mation and uncontrolled confounders are possible.

For example, details of patients characteristics that

might have influenced the response to furosemide

or the combination regimen may have been missed.

Because of limited enrollment, we did not perform

subgroup analyses to evaluate whether albumin is

beneficial in specific populations of patients in the

ICU. Furthermore, the limited number of patients at

the final 48-hour end point prohibits firm conclu-

sions about an effect or lack of effect of albumin inenhancing furosemide diuresis with more prolonged

administration. Finally, we evaluated the use of con-

tinuous infusions of albumin and furosemide at

only a single institution, so our results may not be

generalizable to other ICUs.

ConclusionsCompared with continuous infusion of

furosemide alone, administration of furosemide

plus albumin given as a continuous infusion did

not improve urine output in critically ill patients.

Furthermore, cumulative fluid loss did not differ

between the 2 groups. Enhanced urine output was

associated solely with increased fluid intake and not

with other independent variables such as serum

levels of albumin.

ACKNOWLEDGMENTSThis work was performed at the Arizona Health SciencesCenter in Tucson, Arizona.

FINANCIAL DISCLOSURESNone reported.

REFERENCES1. Sanjay S, Annigeri RA, Seshadri R, Rao BS, Prakash KC,

Mani MK. The comparison of the diuretic and natriureticeffect of continuous and bolus intravenous furosemide inpatients with chronic kidney disease. Nephrology (Carlton).2008;13(3):247-250.

2. Asare K. Management of loop diuretic resistance in the inten-sive care unit. Am J Health Syst Pharm. 2009;66:1635-1640.

3. Inoue M, Okajima K, Itoh K, et al. Mechanism offurosemide resistance in analbuminemic rats and hypoal-buminemic patients. Kidney Int. 1987;32(2):198-203.

4. Kirchner KA, Voelker JR, Brater DC. Binding inhibitorsrestore furosemide potency in tubule fluid containing albu-min. Kidney Int. 1991;40:418-424.

5. Akcicek F, Yalniz T, Basci A, Ok E, Mees EJ. Diuretic effect

of furosemide in patients with nephrotic syndrome: is itpotentiated by intravenous albumin? BMJ. 1995;310(6973):162-163.

6. Fliser D, Zurbruggen I, Mutschler E, et al. Coadministrationof albumin and furosemide in patients with the nephroticsyndrome. Kidney Int. 1999;55(2):629-634.

7. Gentilini P, Casini-Raggi V, Di Fiore G, et al. Albuminimproves the response to diuretics in patients with cirrho-sis and ascites: results of a randomized, controlled trial. JHepatol. 1999;30(4):639-645.

8. Chalasani N, Gorski JC, Horlander JC, et al. Effects of albu-min/furosemide mixtures on responses to furosemide inhypoalbuminemic patients. J Am Soc Nephrol. 2001;12(5):1010-1016.

9. Martin GS, Moss M, Wheeler AP, Mealer M, Morris JA,Bernard GR. A randomized, controlled trial of furosemidewith or without albumin in hypoproteinemic patients withacute lung injury. Crit Care Med. 2005;33(8):1681-1687.

10. Dorhout Mees EJ. Does it make sense to administer albu-min to the patient with nephrotic oedema? Nephrol DialTransplant. 1996;11(7):1224-1226.


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CNE Test Test ID A1221043: Effect of Albumin on Diuretic Response to Furosemide in Patients With Hypoalbuminemia.Learning objectives: 1. Examine the effect of albumin on the diuretic effect of furosemide. 2. Correlate findings of various studies related to the sequential admin-istration of albumin and furosemide. 3. Identify study limitations and opportunities for future research related to administration of furosemide and albumin.

Program evaluation Yes NoObjective 1 was met Objective 2 was met Objective 3 was met Content was relevant to my

nursing practice My expectations were met This method of CE is effective

for this content The level of difficulty of this test was:

easy medium difficultTo complete this program,

it took me hours/minutes.

Test ID: A1221043 Contact hours: 1.0 Form expires: July 1, 2014.Test Answers: Mark only one box for your answer to each question. You may photocopy this form.

1. Which of the following is the most frequently used treatment forvolume overload in critically ill patients?a. Thiazide diuretics and fluid restrictionb. Fluid restriction and albuminc. Fluid restriction and loop diureticsd. Albumin and thiazide diuretics

2. Which of the following is the primary objective of this study?a. To compare urinary output in patients given furosemide and albumin injections

every 6 hoursb. To compare urinary output in patients given furosemide alone with output in

patients given both furosemide and albuminc. To compare urinary output in patients given furosemide alone with output in

patients given furosemide and thiazide diureticd. To compare urinary output in patients given furosemide alone with output in

patients given furosemide and thiazide diuretics

3. Which of the following statements best describes the study design?a. Adult patients in a medical intensive care unit (ICU) receiving a continuous

furosemide infusion with and without 25% albumin; diuretic effect measuredat 30-minute increments

b. All adult ICU patients receiving a continuous thiazide infusion with and

without 25% albumin; diuretic effect measured at 3 hours and 6 hoursc. Adult patients in an MICU receiving a continuous furosemide infusion with andwithout 25% albumin; diuretic effect measured at 6 hours for primary endpoint

d. All adult patients in an MICU receiving a continuous furosemide infusionwith and without 25% albumin; diuretic effect measured at 30-minute increments

4. Which patients were excluded from the study?a. Those who did not have sequential infusions of albumin and furosemide;

renal dysfunction, hypokalemiab. Those who had sequential infusions of albumin and furosemide; incomplete

intake and output records, serum creatinine 1.0c. Those who did not have sequential infusions of albumin and furosemide;

renal dysfunction, current renal diseased. Those who had sequential infusions of albumin and furosemide; renal

dysfunction, current renal disease

5. Which of the following baseline data poi nts were collected onall patients?a. Age, sex, height, weight, serum creatinine, diuretic medications, ICU diagnosisb. Age, sex, height, weight, urine creatinine, diuretic medications, ICU diagnosisc. Age, sex, height, weight, serum creatinine, cardiac medications, ICU diagnosisd. Age, sex, height, weight, urine creatinine, cardiac medications, ICU diagnosis

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6. How many patients would be needed to detect a 30% difference in urineoutput between f urosemide alone and the al bumin plus f urosemidegroup?a. 53b. 67c. 170d. 22

7. How many patients were in the final study?a. 170b. 31c. 36d. 14

8. What were the 3 most common underlying illnesses seen in the patientsin this study?a. Skin cancer, respiratory disease, cardiovascular diseaseb. Skin cancer, pancreatitis, hepatitis Cc. Skin cancer, liver disease, respiratory diseased. Skin cancer, cardiovascular disease, liver disease

9. Which of the following was the only signif icant predictor of increased

urina ry output for both the furosemide and the furosemide plus albumingroup at 24 and 48 hours?a. Fluid intakeb. Rate of furosemide infusionc. Rate of albumin infusiond. Time interval between furosemide and albumin infusion

10. Which of the following statements best describes the effect ofcoadmini stration of furosemide and albumi n?a. Effect was greater than the continuous infusion of furosemide aloneb. Effect was the same for furosemide infusion alone and furosemide and albumin

administrationc. Effect was no greater than the continuous infusion of furosemide aloned. Effect was significantly greater than the continuous infusion of furosemide alone

11. Which of the following is the recommended treatment if loop diuretic

resistance continues?a. Add 20% albuminb. Add loop diureticc. Add fluidd. Add thiazide diuretic

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