Diuretics decrease fluid balance in patients on invasive mechanical ventilation: the randomized-controlled single blind, IRIHS study

Abstract

Background Fluid overload has been associated with increased morbidity and mortality in critically ill patients. The goal of this study was to assess the efficacy and safety of a diuretic strategy to overcome positive fluid balance in patients on invasive mechanical ventilation. Methods Design: Multicenter, single-blind, randomized-controlled study. Patients were randomized into a diuretic (furosemide) or a control group. Patients were eligible in case of fluid overload defined as in-ICU weight increase ≥ 3%, invasive mechanical ventilation (FiO2 ≤ 60% and PEEP ≤ 10 cm H2O on inclusion) and hemodynamic stabilization. The primary outcome was fluid balance, defined as weight variation from reference weight to successful extubation. The main secondary outcome was the safety of diuretic. Results 171 patients were randomized. After 5 exclusions, 166 patients were included in the analysis: 77 in the diuretic and 89 in the control group. Fluid balance was 1.4 [− 2.5 to 4.5] kg in the diuretic and 6.4 [0.5–11.2] kg in the control group (p < 0.001). In the multiple imputation analysis, fluid balance was significantly decreased in the diuretic group (mean difference = − 4.8 95% CI [− 7.3 to − 2.5], p < 0.001). Eleven (14%) patients died in the diuretic group and 16 (18%) patients in the control group (p = 0.5). There was a worsening of Acute Kidney Injury in 67 (75.3%) patients of the control group versus 46 (59.7%) patients in the diuretic group (p = 0.03). Conclusions In this multicenter randomized-controlled study, protocolized diuretic therapy reduced fluid accumulation in patients receiving mechanical ventilation and was well tolerated with a favorable safety profile. Trial registration NCT 02345681, Registered January 26 2015, Prospectively registered, https://clinicaltrials.gov/ct2/show/NCT02345681?term=02345681&draw=2&rank=1.

Loop diuretics in adult intensive care patients with fluid overload: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis

“…As experimental intervention, nine trials used furosemide and one trial used torsemide. The control group interventions consisted of: no diuretics [ 54 , 56 , 57 ]; placebo [ 52 ]; standard of care [ 37 , 55 ]; a different loop diuretic (piretanide, ethacrynic acid) [ 58 , 59 ]; or a different group of diuretics (tolvaptan, acetazolamide) [ 53 , 60 ]. Albumin is the carrier for furosemide and hypoalbuminemia might result in decreased effect of the drug.…”

“…40 mg/hour. If furosemide was not efficient enough according to protocol dialysis was initiated Standard of care Yes (100%) 5 days Cumulative fluid balance 5 days after randomisation Cardoso 2013 [ 55 ] Brazil 72 Cardiac ICU Decompensated heart failure 120 mg of furosemide followed by titration according to effect Standard of care Not reported a 10 days Time to being free from congestion Cinotti 2021 [ 54 ] France 171 Mixed ICU Mixed ICU patients Furosemide 1–2 times a day. Max.…”

Molecular Basis, Diagnostic Challenges and Therapeutic Approaches of Bartter and Gitelman Syndromes: A Primer for Clinicians

“…Diuretics are active natriuretic principles that modify electrolyte transport and are widely used for the treatment of hypertension, heart failure, and fluid overload [ 120 , 121 ]. The main idea of conducting a diuretic test is to demonstrate the lack of effect in patients with GS and BS [ 122 , 123 ].…”

Association between early cumulative fluid balance and successful liberation from invasive ventilation in COVID-19 ARDS patients — insights from the PRoVENT-COVID study: a national, multicenter, observational cohort analysis

“…Excessive fluid administration may increase the risk of pulmonary complications and the effects of edema in vital organs, causing injury [ 8 , 9 ]. On the other hand, a restrictive fluid strategy could lead to extrapulmonary organ dysfunction consequent to reduced cardiac output; however, more recent evidence suggests mixed results in critically ill patients [ 10 , 11 ]. Therefore, the fluid balance being an adverse prognostic factor, yet also a potentially modifiable risk factor, poses a unique dilemma in the management of critically ill COVID-19 patients.…”