Intermittent Bolus Group Research Articles

Continuous Infusion versus Intermittent Bolus Injections of Furosemide in Congestive Heart Failure

Abstract Background Loop diuretic therapy (Furosemide) plays a pivotal role in the treatment of CHF. Despite the lack of mutual agreement about the best approach to use Furosemide in CHF, its demonstrated efficacy and the long clinical experience with it suggest that it will remain an integral part in management of the CHF. Ongoing investigation into the optimal strategy to administer furosemide is a must to maintain its efficacy and minimize its adverse effects. Aim of the Work To compare continuous infusion and bolus intermittent injection of Furosemide in patients admitted with congestive heart failure. Patients and Methods In our study we tried to distinguish the most useful method of Furosemide administration whether continuous infusion or intermittent bolus injections. 40 patients (31 males and 9 females) admitted with a diagnosis of CHF were randomized in 1:1 ratio into either continuous infusion or intermittent boluses of Furosemide. On patient admission, detailed history was taken including symptoms, risk factors and etiology. Clinical examination was performed to detect rales, other signs of pulmonary edema and peripheral edema. Body weight measurement was taken as a baseline. All patients were submitted to CXR, echocardiography and laboratory assessment of renal function and electrolytes. Results Patients were then compared daily regarding BWL, UOP and clinical improvement of pulmonary rales. They were monitored for electrolytes disturbance, renal function deterioration and hemodynamic instability for first 72 hours after admission. The length of ICU stay and mortality were observed as well. Our study revealed that Furosemide administered in continuous infusion group, in comparison with intermittent bolus group, was associated with more cumulative UOP (P value 0.002) and more total BWL in 3 days (P value 0.000). This was on the expense of more incidence of hypokalemia (P value 0.002), there was no significant difference between 2 routes regarding hemodynamic parameters, renal function, mortality or length of ICU stay. Conclusion Continuous infusion of Furosemide in patients with CHF appears to provide more efficient diuresis, together with more reduction of body weight when compared to intermittent bolus therapy. However, these obtained beneficial hemodynamic effects were not reflected on the clinical course and patient outcome. Moreover, they were associated with electrolyte disturbance.

Safety and efficacy of target-controlled infusion versus intermittent bolus administration of propofol for sedation in colonoscopy: a randomized controlled trial

BackgroundOur objective was to compare the safety and efficacy of Target-Controlled Infusion (TCI) versus intermittent bolus of propofol for colonoscopy sedation. MethodsWe conducted a randomized (1:1), single-blind, parallel-group superiority trial with fifty ASA I or II patients, both sexes, aged 18 to 65 years, Body Mass Index ≤ 30 kg.m−2, undergoing colonoscopy, allocated to receive propofol by TCI (effect-site, 2 μg.mL−1 plus 0.5 μg.mL−1 until unconsciousness and as necessary for agitation) or intermittent bolus (1 mg.kg−1 plus 0.5 mg.kg−1 every 5 minutes or as above). The primary safety outcome was the need for airway maneuvers and the primary efficacy outcome was the need for interventions to adjust the level of sedation. Secondary outcomes included incidence of agitation, propofol dose, and time to recovery. ResultsThe median (IQR) number of airway maneuvers and interventions needed to adjust sedation was 0 (0‒0) vs. 0 (0‒0) (p = 0.239) and 1 (0‒1) vs. 3 (1‒4) (p < 0.001) in the TCI and control groups, respectively. Agitation was more common in the intermittent bolus group ‒ 2 (0‒2) vs. 1 (0‒1), p < 0.001. The mean ± SD time to recovery was 4.9 ± 1.4 minutes in the TCI group vs. 2.3 ± 1.6 minutes in the control group (p < 0.001). The total propofol dose was higher in the TCI group (234 ± 46 µg.kg−1.min−1 vs. 195 ± 44 µg.kg−1.min−1 (p = 0.040)). ConclusionsDuring colonoscopy, TCI is as safe as intermittent bolus of propofol while reducing the incidence of agitation and the need for dose adjustments. However, intermittent bolus administration was associated with lower total propofol dose and earlier recovery.

Early diuretic strategies and the association with In-hospital and Post-discharge outcomes in acute heart failure

Decongestion is a primary goal during hospitalizations for decompensated heart failure (HF). However, data surrounding the preferred route and strategy of diuretic administration are limited with varying results in prior studies. This is a retrospective analysis using patients from ASCEND-HF with a stable diuretic strategy in the first 24 hours following randomization. Patients were divided into three groups: intravenous (IV) continuous, IV bolus and oral strategy. Baseline characteristics, in-hospital outcomes, 30-day composite cardiovascular mortality or HF rehospitalization and 180-day all-cause mortality were compared across groups. Inverse propensity weighted modeling was used for adjustment. Among 5,738 patients with a stable diuretic regimen in the first 24 hours (80% of overall ASCEND trial), 3,944 (68.7%) patients received IV intermittent bolus administration of diuretics, 799 (13.9%) patients received IV continuous therapy and 995 (17.3%) patients with oral administration. Patients in the IV continuous group had a higher baseline creatinine (IV continuous 1.4 [1.1-1.7]; intermittent bolus 1.2 [1.0-1.6]; oral 1.2 [1.0-1.4] mg/dL; P <0.001) and high NTproBNP (IV continuous 5,216 [2,599-11,603]; intermittent bolus 4,944 [2,339-9,970]; oral 3,344 [1,570-7,077] pg/mL; P <0.001). There was no difference between IV continuous and intermittent bolus group in weight change, total urine output and change in renal function till 10 days/discharge (adjusted P >0.05 for all). There was no difference in 30 day mortality and HF readmission (adjusted OR 1.08 [95%CI: 0.74, 1.57]; P=0.701) and 180 days mortality (adjusted OR 1.04 [95%CI: 0.75, 1.43]; P=0.832). In a large cohort of patients with decompensated HF, there were no significant differences in diuretic-related in-hospital, or post-discharge outcomes between IV continuous and intermittent bolus administration. Tailoring appropriate diuretic strategy to different states of acute HF and congestion phenotypes needs to be further investigated.

Differences between Continuous Infusion and Intermittent Bolus of Furosemide with Length of Hospital Stay in Patients with Acute Heart Failure in Haji Adam Malik General Hospital Medan

Background: Heart failure is a complication that often occurs in individuals with or without underlying cardiovascular disease. Furosemide serves to reduce preload and improve congestion symptoms. The aim of this study was to determine the difference in length of hospital stay between continuous infusion and intermittent bolus of furosemide in patients with acute heart failure.Methods: This study was a prospective-single blind-randomized controlled study of 54 people with acute heart failure who entered the emergency room and underwent treatment at the H. Adam Malik Hospital from October 2018 to March 2019. Re-examination of urine production, kidney function, and electrolytes was carried out after 72 hours of treatment. Subsequent subjects were observed during treatment for death during treatment and duration of treatment. Follow-up was carried out for 30-days to assess rehospitalization.Results: Between continuous infusion group and intermittent bolus group, we found, respectively, length of hospital stay 7.6±3.2 vs. 7.3±4.8 days, p=0.28; urine production 2241±429 vs 2020±368, p=0.048; ∆BUN 3.6 ± 14.5 vs 4.0 ± 10.9, p=0.91; ∆Ureum 7.9 ± 31.0 vs 8.5 ± 23.3; p=0.92; ∆Creatinine 0.1 ± 0.61 vs. 0.03 ± 0.33; p=0.56; and ∆GFR -5.5 ± 20.6 vs -2.7 ± 22.7; p=0.64. In terms of mortality during hospitalization, we found that 7.4% vs 11.1%, p=0.63 (HR 0.64; 95% CI: 0.098–4.1) and rehospitalization in 30 days showed 22.2% vs 37%; p=0.23 (HR 0.48; 95% CI: 0.14–1.6) in continuous infusion vs. intermittent bolus group, respectively.Conclusions: In patients with acute heart failure, there is no difference between continuous infusion and intermittent bolus of furosemide in regard to length of hospital stay, changes in renal function and electrolyte, death during hospitalization, and rehospitalization within 30-days. However, continuous administration of furosemide infusion is better in urine production.

Continuous infusion versus intermittent bolus doses of fentanyl for analgesia and sedation in neonates: an open-label randomised controlled trial

ObjectiveAdequate data on fentanyl pharmacokinetics in neonates are lacking. The study was performed to compare serum concentrations and clinical outcome between continuous infusion (CI) and intermittent bolus (IB) doses of...

Clinical outcomes of prolonged infusion (extended infusion or continuous infusion) versus intermittent bolus of meropenem in severe infection: A meta-analysis.

BackgroundMeropenem exhibits time-dependent antimicrobial activity and prolonged infusion (PI) (extended infusion or continuous infusion, EI or CI) of meropenem can better achieve pharmacodynamics target when comparing with intermittent bolus (IB). However, the clinical outcomes between two groups remain inconclusive.ObjectiveTo evaluate current published literatures by meta-analysis to ascertain whether PI of meropenem can improve clinical outcomes.MethodsMedline, Cochrane database and EMBASE were searched. Randomized control trails (RCT) and observational studies which compared the clinical outcomes of PI and IB groups were included and evaluated for quality. The data of studies were extracted and meta-analysis was performed using Revman 5.3 software.ResultsSix RCTs and 4 observation studies with relatively high quality were included in this analysis. Compared to IB group, PI group had a higher clinical success rate (odd ratio 2.10, 95% confidence interval 1.31–3.38) and a lower mortality (risk ratio 0.66, 95% confidence interval 0.50–0.88). The sensitivity analysis showed the results were stable.ConclusionPI of meropenem was associated with a higher clinical improvement rate and a lower mortality. It is recommended for patients with severe infection or infected by less sensitive microbial.

Continuous transversus abdominis plane block vs intermittent bolus for analgesia after abdominal surgery: a randomized trial

BackgroundContinuous and intermittent bolus techniques of transversus abdominis plane (TAP) blocks have been used for analgesia after abdominal surgery. Although both are effective, there are no studies comparing them. The aim of this study is to compare analgesia and cost-effectiveness between these groups.MethodsAfter obtaining ethical approval, 20 American Society of Anesthesiologists ASA grade I to III patients undergoing elective abdominal surgery were recruited with 10 patients allocated to each arm. Bilateral ultrasound-guided TAP blocks were performed with an initial bolus of 0.5% ropivacaine 20 mL per side, followed by catheter insertion. After surgery, the continuous infusion group received 0.2% ropivacaine 8 mL/hour on each side and the intermittent bolus group received doses of 0.2% ropivacaine 20 mL per side every 8 hours for 48 hours. Both groups received intravenous fentanyl patient-controlled analgesia and regular oral paracetamol. Parameters recorded included numerical rating scores for pain and post-operative analgesic consumption at baseline (time 0) and at 1 hour, 1 day and 2 days post-operatively. The duration of catheter insertion, complications, patient satisfaction and information regarding costs were also recorded. Patient satisfaction was assessed utilizing a 4-point “Likert” scale on day 2 and on day 30. Pain and Likert scores were analysed by non-parametric sum rank test and all two-sampled t-tests assumed unequal variances.ResultsThere was no difference between duration of TAP block, anesthetic and surgical technique and length of stay (p=0.23). Primary outcomes: pain scores at rest and cough were not significantly different (p=0.20) between the groups. Satisfaction scores were similar at day 2 and 30 (p=0.77). However, the bolus group was more cost-effective (AU$347.98 vs AU$429.43).ConclusionContinuous or bolus TAP blocks are effective analgesic techniques in abdominal surgery, with bolus technique being more economical.

Intermittent Bolus versus Continuous Infusion of Propofol for Deep Sedation during ABR/Nuclear Medicine Studies.

Objective A comparison of intermittent bolus (IB) versus continuous infusion of propofol for deep sedation. Material and Methods A retrospective review of patients sedated for Auditory Brainstem Response (ABR)/nuclear medicine studies between September 2008 and February 2015. A ketamine bolus (0.5 mg/kg < 20 kg, 0.25 mg/kg > 20 kg) followed by propofol bolus of 1 mg/kg over 2 minutes. In the IB group, maintenance of deep sedation was with incremental bolus of 10 to 20 mg of propofol. In continuous infusion group (CG), maintenance was with a continuous infusion of 83 mcg/kg/min of propofol. Results Of the 326 cases completed, 181 were in CG group and 145 were in IB group. There were no statistical differences in patient's age, weight, and American Society of Anesthesiologist (ASA) classification. The cardiovascular and respiratory parameters in the two groups were not different statistically. Mean total propofol dose was higher in CG group versus IB group (CG 7.6 mg ± 3.6 mg, IB 6.5 mg ± 3.6 mg; p = 0.008). Procedure time in CG group was longer by 8 minutes compared with IB group (CG 49.8 min ± 25.4 min versus 42.3 min ± 19.2 min; p = .003). CG group has both shorter recovery time (CG 8.1 min ± 4.7 min versus IB 10.0 min ± 8.5 min; p = 0.01) and discharge time. Conclusion Satisfactory sedation and completion of the procedure was accomplished with both sedation protocols.

The efficacy of automated intermittent boluses for continuous femoral nerve block: a prospective, randomized comparison to continuous infusions

Study ObjectiveTo determine whether an automated intermittent bolus technique provides enhanced analgesia compared with a continuous infusion for femoral nerve block. DesignProspective, single-blinded, randomized controlled trial (ClinicalTrials.gov Identifier: NCT01226927). SettingPerioperative areas and orthopedic surgical ward of a university hospital. Patients45 ASA physical status 1, 2, and 3 patients undergoing unilateral primary total knee arthroplasty. InterventionsAll patients received single-injection sciatic and femoral nerve blocks plus femoral nerve catheter placement for postoperative analgesia. Patients were randomly assigned to an automated intermittent bolus (5 mL every 30 min with 0.1 mL/hr basal rate) or a continuous infusion (10.1 mL/hr) delivery method of 0.2% ropivacaine. MeasurementsConsumption of intravenous patient-controlled analgesia (IV-PCA) and visual analog scale (VAS) pain scores were assessed postoperatively at set intervals until the morning of postoperative day (POD) 2. Main ResultsThe mean (SEM) cumulative IV-PCA dose (mg of hydromorphone) for the 36-hour postoperative interval measured was 12.9 ± 2.32 in the continuous infusion rate group (n = 20) and 7.8 ± 1.02 in the intermittent bolus group [n = 21, t(39) = 2.04, P = 0.048; a 39 ± 14% difference in total usage]. Pain scores were statistically significantly lower in the intermittent bolus group in the afternoon of POD 1 (t(39) = 2.47, P = 0.018), but were otherwise similar. ConclusionsAn automated intermittent bolus infusion technique for femoral nerve catheters is associated with clinically and statistically significantly less IV-PCA use (ie, an opioid-sparing effect) than a continuous infusion technique.

Continuous Infusion versus Intermittent Bolus Dosing of Vecuronium in Patients Receiving Therapeutic Hypothermia After Sudden Cardiac Arrest

To compare the effects of vecuronium administered as an intravenous continuous infusion versus intermittent bolus doses in patients treated with therapeutic hypothermia after sudden cardiac arrest (SCA). Design. Retrospective medical record review. Cardiac care unit of a university-affiliated, level I trauma center. Of 123 adults treated with therapeutic hypothermia after SCA, 80 received continuous-infusion vecuronium 0.8 μg/kg/minute started 2 hours after cooling began or if shivering occurred (January 1, 2004-December 31, 2007), and 43 received intermittent boluses of vecuronium 0.05 mg/kg every 2 hours (January 1, 2008-September 30, 2009). The degree of neuromuscular blockade was measured with a train-of-four (TOF) test. Primary outcomes evaluated were time to achieve goal TOF response and percentage of time the TOF response was maintained at goal. Secondary outcomes included total daily dose of vecuronium, the vecuronium dose needed to achieve goal TOF response, percentage of TOF measurements above or below goal, and time to return of spontaneous respirations and time to extubation after the last dose of vecuronium. The goal TOF response was achieved significantly earlier in the bolus group than the continuous-infusion group (mean 5.9 vs 11.3 hrs, p=0.008). The mean total daily dose of vecuronium administered in the bolus group was significantly lower than that in the continuous-infusion group (51.7 vs 76.9 mg, p=0.002). The mean percentage of TOF measurements above goal was higher in the continuous-infusion group (33% vs 16%, p<0.0001), and the mean percentage of TOF measurements below goal was higher in the bolus group (43% vs 29%, p<0.0001). The median time to return of spontaneous respirations (6 vs 11 hrs, p=0.017) and time to extubation (29.5 vs 89.5 hrs, p<0.0001) were significantly shorter in the continuous-infusion group than the bolus group. Intermittent boluses of vecuronium were more effective in reaching a goal TOF response earlier compared with continuous-infusion vecuronium in patients treated with therapeutic hypothermia. The two dosing strategies were equally effective at maintaining a goal TOF response despite patients receiving a significantly lower daily dose of vecuronium in the intermittent-bolus group.

Comparison of Automated Intermittent Low Volume Bolus with Continuous Infusion for Labour Epidural Analgesia

Delivery of local anaesthetics via automated intermittent bolus has been shown to improve epidural analgesia compared to delivery via continuous epidural infusion. However the optimal bolus volume has not been investigated. This randomised, double-blind study compared the analgesic efficacy of automated intermittent bolus (volume 2.5 ml every 15 minutes) with that of a continuous epidural infusion (10 ml/hour) for the maintenance of labour epidural analgesia, to determine whether the advantages previously demonstrated for automated intermittent bolus over continuous epidural infusion are retained at this low bolus volume. With the approval of the Hospital Ethics Committee, we recruited 50 parturients who received combined spinal epidural analgesia with intrathecal ropivacaine 2 mg and fentanyl 15 microg. For epidural maintenance, participants were randomised to either the automated intermittent bolus group (2.5 ml automated intermittent epidural boluses of ropivacaine 0.1% plus fentanyl 2 microg/ml delivered over a two-minute period every 15 minutes) or the continuous epidural infusion group (continuous epidural infusion of ropivacaine 0.1% plus fentanyl 2 microg/ml at 10 ml/hour). The primary study outcome was the incidence of pain during labour that required management with supplemental epidural analgesia. There were no significant differences between the two regimens in terms of breakthrough pain (automated intermittent bolus 36% [9/25] vs continuous epidural infusion 32% [8/25], P = 0.77). At the doses used in this study, maintenance of labour analgesia using automated intermittent bolus at a bolus volume of 2.5 ml every 15 minutes does not decrease the incidence of breakthrough pain or improve analgesic efficacy compared to continuous epidural infusion.

Reporting the Results of a Study That Did Not Go According to Plan

Reporting the Results of a Study That Did Not Go According to Plan

Continuous axillary brachial plexus block for postoperative pain relief: Intermittent bolus versus continuous infusion

The aim of this study was to compare the efficacy and safety of continuous axillary brachial plexus block by infusion and by intermittent injection of bupivacaine 0.25% in the management of postoperative pain. Two methods of continuous axillary brachial plexus block for pain management were compared in a prospective randomized trial. Twenty 16- to 62-year-old male patients (ASA I and II), undergoing microsurgery, received 0.25% bupivacaine following surgery, by either continuous infusion (group C, n = 10), or intermittent hourly bolus (group B, n = 10), via an axillary brachial plexus catheter inserted prior to operation. Efficacy assessments and analysis of plasma bupivacaine levels were performed for up to 38 hours postsurgery. There was no difference between groups with respect to pain scores, degree of motor block, or supplemental narcotic requirements. Plasma bupivacaine levels were higher in group C, with the difference reaching significance after 26 hours (means +/- SEM: C = 1.03 +/- 0.10 micrograms/mL, B = 0.73 +/- 0.08 microgram/mL, P < .05). There were no significant differences in cumulative bupivacaine doses or infusion rates between the groups. Complications included one case of axillary artery puncture at insertion, two unplanned premature catheter removals, and a self-limited grand mal convulsion in a known epileptic. Overall, both techniques provided safe and effective postoperative analgesia. As compared with continuous infusion, intermittent bolus administration resulted in lower plasma bupivacaine levels despite similar infusion rates.

Postoperative Epidural Opioid Analgesia

Postoperative Epidural Opioid Analgesia

Epidural patient-controlled analgesia (PCA): an alternative to continuous epidural infusions

In a clinical study involving 16 surgical patients receiving epidural hydromorphone for postoperative analgesia, we compared the use of a continuous infusion technique to an intermittent bolus technique (involving the use of a PCA device). Although comparable analgesia was achieved in the 2 treatment groups during the 48 h study period, the hydromorphone usage (mean value ± S.D.) was significantly higher in the continuous infusion group (10.2 ± 3.6 mg vs. 4.6 ± 2.2 mg in the intermittent bolus group). In spite of this difference in the analgesic dosage requirement, the side effect profile was similar for the 2 groups. Further studies are needed to confirm this observation and to determine the implications with respect to postoperative recovery.