Impact of protocolized diuresis for de-resuscitation in the intensive care unit

Abstract

Objective: Administration of diuretics has been shown to assist fluid management and improve clinical outcomes in the critically ill post-shock resolution. Current guidelines have not yet included standardization or guidance for diuretic-based de-resuscitation in critically ill patients. This study aimed to evaluate the impact of a multi-disciplinary protocol for diuresis-guided de-resuscitation in the critically ill. Methods: This was a pre-post single-center pilot study within the medical intensive care unit (ICU) of a large academic medical center. Adult patients admitted to the Medical ICU receiving mechanical ventilation with either (1) clinical signs of volume overload via chest radiography or physical exam or (2) any cumulative fluid balance ≥ 0 mL since hospital admission were eligible for inclusion. Patients received diuresis per clinician discretion for a 2-year period (historical control) followed by a diuresis protocol for 1 year (intervention). Patients within the intervention group were matched in a 1:3 ratio with those from the historical cohort who met the study inclusion and exclusion criteria. Results: A total of 364 patients were included, 91 in the protocol group and 273 receiving standard care. Protocolized diuresis was associated with a significant decrease in 72-h post-shock cumulative fluid balance [median, IQR − 2257 (− 5676-920) mL vs 265 (− 2283-3025) mL; p < 0.0001]. In-hospital mortality in the intervention group was lower compared to the historical group (5.5% vs 16.1%; p = 0.008) and higher ICU-free days (p = 0.03). However, no statistically significant difference was found in ventilator-free days, and increased rates of hypernatremia and hypokalemia were demonstrated. Conclusions: This study showed that a protocol for diuresis for de-resuscitation can significantly improve 72-h post-shock fluid balance with potential benefit on clinical outcomes.

Fluid management in ARDS: an evaluation of current practice and the association between early diuretic use and hospital mortality

“…Prior studies have demonstrated that most fluids administered in critical care are given with medications rather than as bolus or maintenance crystalloid [ 33 , 34 ]. Our study corroborates these findings that crystalloid used for resuscitation is typically a less significant contributor to net fluid balance than diuretic use and incidental fluids in the ARDS population [ 29 , 35 – 38 ].…”

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

“…In a multicentric cohort of patients with acute kidney injury [19], the use of diuretics was associated with increased mortality by day-60. However, in more recent cohorts [26,27], diuretics were associated with decreased mortality and improved kidney function. Thus, the use of diuretics in the ICU to control fluid balance could be promising, but there is little evidence regarding the benefit/risk ration of this medication in critically ill patients.…”

Examination of critical care pharmacist work activities and burnout

“…In Give and Take, Adam Grant discusses the power of an individual's professional generosity to support wellness and future success 26 . Teaching, which combines both intellectual engagement of conveying complex material with the power of connection, may be a powerful protector against burnout while also serving as a meaningful way to optimize patient outcomes 37‐40 . Identifying strategies to maximize this vital role of the critical care pharmacist in the health care setting is warranted.…”