Frusemide has been the topic of multiple primary exam questions, but in the Part Two the first serious mention of this drug came in the form of Question 7 from the first paper of 2019. The college asked about "the role of frusemide" in Intensive Care, including "potential indications, proposed benefits, adverse effects and a summary statement of the available evidence". Though the "potential indications" for frusemide include multiple non-renal applications, the bulk of Question 7 focused on the evidence behind its use in renal failure, specifically as a means of delaying or preventing dialysis in renal failure patients with fluid overload. That is the rationale for putting this undifferentiated question into the "renal failure and dialysis" section.
The free article by Ho & Power (2010) is probably enough as a single reference to answer Question 7. Joannidis et al (2019) have published an excellent (free) editorial in Intensive Care Medicine which answers some of the misconceptions regarding the uses of frusemide, but it is probably not enough of a review by itself.
Uses of frusemide in Intensive Care patients are numerous, and it would be difficult to group them under "rationale" or "indications", particularly as not everybody would agree to every indication. Instead, it would probably be better to divide the physiological effects of frusemide as "useful" or "not useful", to discuss the various ways in which it has been applied in critical care, and to evaluate the evidence for these applications.
Though Question 7 from the first paper of 2019 ostensibly asked about the role of frusemide in all intensive care patients, of its 580-word college answer 323 words were dedicated to exploring the controversial use of loop diuretics in renal failure. Proportionally to this allocation of examiner attention, the topic of frusemide in renal failure deserves a thorough dissection. Fortunately, Ho & Power (2010) have an excellent series of tables at the end of their article which has been pillaged for the content of what follows:
Rationale for the use of frusemide in renal failure patients
Proposed beneficial effects of frusemide in renal failure
Caveats to the use of frusemide in renal failure
Evidence for the use of frusemide in renal failure
To discuss one's own approach to a contentious problem is usually advisable in a "critically evaluate" question, but "own practice" is not always called for. "Many candidates chose to describe their own practice, not answering the question asked", complained the college examiners in their comments to Question 7 from the first paper of 2019, who clearly just wanted "a summary statement of the available evidence". However, there may come a time when a description of one's own practice may be called for.
Jones et al (2015) surveyed the locals and published their results in Critical care and Resuscitation, which would have been relatively straightforward as the chief editor was one of the co-authors. It turns out that we Australian intensivists do not tend to use frusemide for acute kidney injury. The most common dose was a 40mg IV bolus, the most common indications were acute pulmonary oedema and a positive fluid balance. The exam candidate who confesses to some sort of similar practice will therefore be in good company.
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