Use of diuretics in shock: Temporal trends and clinical impacts in a propensity-matched cohort study

Bandak, Ghassan; Sakhuja, Ankit; Andrijasevic, Nicole; Gunderson, Tina M.; Gajić, Ognjen; Kashani, Kianoush

doi:10.1371/journal.pone.0228274

Cited by 8 publications

(11 citation statements)

References 34 publications

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“…We found no difference in the management of patients by these factors, demonstrating that they are not clinical exclusions to diuretic use in usual care. The benefits of conservative fluid management and the use of diuretics may be generalizable to these populations, which would be consistent with clinician surveys and observational studies [ 30 – 32 ].…”

Section: Discussionsupporting

confidence: 69%

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

2020

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Background Acute respiratory distress syndrome (ARDS) and volume overload are associated with increased hospital mortality. Evidence supports conservative fluid management in ARDS, but whether current practice reflects the implementation of that evidence has not been described. This study reports the variability in contemporary fluid management for ICU patients with ARDS. We compared routine care to trial protocols and analyzed whether more conservative management with diuretic medications in contemporary, usual care is associated with outcomes. Methods We performed a retrospective cohort study in nine ICUs at two academic hospitals during 2016 and 2017. We included 234 adult patients with ARDS in an ICU at least 3 days after meeting moderate-severe ARDS criteria (PaO2:FIO2 ≤ 150). The primary exposure was any diuretic use in 48 to 72 h after meeting ARDS criteria. The primary outcome was hospital mortality. Unadjusted statistical analyses and multivariable logistic regression were used. Results In 48–72 h after meeting ARDS criteria, 116 patients (50%) received a diuretic. In-hospital mortality was lower in the group that received diuretics than in the group that did not (14% vs 25%; p = 0.025). At ARDS onset, both groups had similar Sequential Organ Failure Assessment scores and ICU fluid balances. During the first 48 h after ARDS, the diuretic group received less crystalloid fluid than the no diuretic group (median [inter-quartile range]: 1.2 L [0.2–2.8] vs 2.4 L [1.2-5.0]; p < 0.001), but both groups received more fluid from medications and nutrition than from crystalloid. At 48 h, the prevalence of volume overload (ICU fluid balance >10% of body weight) in each group was 16% and 25%(p = 0.09), respectively. During 48–72 h after ARDS, the overall prevalence of shock was 44% and similar across both groups. Central venous pressure was recorded in only 18% of patients. Adjusting for confounders, early diuretic use was independently associated with lower hospital mortality (AOR 0.46, 95%CI [0.22, 0.96]). Conclusions In this sample of ARDS patients, volume overload was common, and early diuretic use was independently associated with lower hospital mortality. These findings support the importance of fluid management in ARDS and suggest opportunities for further study and implementation of conservative fluid strategies into usual care.

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Section: Discussionsupporting

confidence: 69%

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

2020

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“…The reason might be due to the fact that furosemide, prescribed at the discretion of the attending specialists in the fields of critical care medicine, not only was used to treat edema but also was given as a preventive intervention. The potential benefits of loop diuretics have been demonstrated, in which diuretic use augments the average hourly urine output in critically ill patients receiving vasopressors ( 30 ), and the daily fluid balance in critically ill patients with a positive fluid balance is consistently lower, when receiving loop diuretics ( 12 ). These results suggest that diuretics can be used to achieve the early fluid control in critically ill patients by reducing FO.…”

Section: Discussionmentioning

confidence: 99%

“…It is reasonable to investigate the association between furosemide administration and AKI, because of the potential benefits of preventing or reducing FO ( 12 , 20 , 23 , 30 ). Experimental evidence suggests that the mechanism of furosemide is to reduce oxygen consumption, increase renal blood flow, and inhibit the active reabsorption of sodium chloride.…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, furosemide may aggravate renal obstruction by promoting the aggregation of Tamm Horsfall protein in renal tubules, leading to AKI ( 35 , 36 ). It remains controversial whether AKI per se can be improved by furosemide or not in recent years ( 12 , 20 , 22 , 30 ). Our study failed to demonstrate a significant relationship between furosemide exposure and AKI, although critically ill children who received furosemide experience less mean FO.…”

Section: Discussionmentioning

confidence: 99%

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Association Between Furosemide Exposure and Clinical Outcomes in a Retrospective Cohort of Critically Ill Children

Dai

Chen

et al. 2021

Front. Pediatr.

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Furosemide is commonly prescribed in critically ill patients to increase the urine output and prevent fluid overload (FO) and acute kidney injury (AKI), but not supported by conclusive evidence. There remain conflicting findings on whether furosemide associates with AKI and adverse outcomes. Information on the impact of furosemide on adverse outcomes in a general population of pediatric intensive care unit (PICU) is limited. The aim of the cohort study was to investigate the associations of furosemide with AKI and clinical outcomes in critically ill children.Study Design: We retrospectively reviewed a cohort of 456 critically ill children consecutively admitted to PICU from January to December 2016. The exposure of interest was the use of furosemide in the first week after admission. FO was defined as ≥5% of daily fluid accumulation, and mean FO was considered significant when mean daily fluid accumulation during the first week was ≥5%. The primary outcomes were AKI in the first week after admission and mortality during PICU stay. AKI diagnosis was based on Kidney Disease: Improving Global Outcomes criteria with both serum creatinine and urine output.Results: Furosemide exposure occurred in 43.4% of all patients (n = 456) and 49.3% of those who developed FO (n = 150) in the first week after admission. Patients who were exposed to furosemide had significantly less degree of mean daily fluid accumulation than those who were not (1.10 [−0.33 to 2.61%] vs. 2.00 [0.54–3.70%], P < 0.001). There was no difference in the occurrence of AKI between patients who did and did not receive furosemide (22 of 198 [11.1%] vs. 36 of 258 [14.0%], P = 0.397). The mortality rate was 15.4% (70 of 456), and death occurred more frequently among patients who received furosemide than among those who did not (21.7 vs. 10.5%, P = 0.002). Furosemide exposure was associated with increased odds for mortality in a multivariate logistic regression model adjusted for body weight, gender, illness severity assessed by PRISM III score, the presence of mean FO, and AKI stage [adjusted odds ratio (AOR) 1.95; 95%CI, 1.08–3.52; P = 0.026].Conclusion: Exposure to furosemide might be associated with increased risk for mortality, but not AKI, in critically ill children.

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“…The patient will be without vasoactive drugs and the risk of hypoperfusion is less. The evidence on this subject is sparce and conflicting [ 70 – 72 ]. The timing of prescribing diuretics in the ICU population with fluid overload would be relevant to investigate in a future RCT.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

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

Wichmann

Barbateskovic

Liang

et al. 2022

Ann. Intensive Care

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Background Fluid overload is a risk factor for organ dysfunction and death in intensive care unit (ICU) patients, but no guidelines exist for its management. We systematically reviewed benefits and harms of a single loop diuretic, the predominant treatment used for fluid overload in these patients. Methods We conducted a systematic review with meta-analysis and Trial Sequential Analysis (TSA) of a single loop diuretic vs. other interventions reported in randomised clinical trials, adhering to our published protocol, the Cochrane Handbook, and PRISMA statement. We assessed the risks of bias with the ROB2-tool and certainty of evidence with GRADE. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42020184799). Results We included 10 trials (804 participants), all at overall high risk of bias. For loop diuretics vs. placebo/no intervention, we found no difference in all-cause mortality (relative risk (RR) 0.72, 95% confidence interval (CI) 0.49–1.06; 4 trials; 359 participants; I2 = 0%; TSA-adjusted CI 0.15–3.48; very low certainty of evidence). Fewer serious adverse events were registered in the group treated with loop diuretics (RR 0.81, 95% CI 0.66–0.99; 6 trials; 476 participants; I2 = 0%; very low certainty of evidence), though contested by TSA (TSA-adjusted CI 0.55–1.20). Conclusions The evidence is very uncertain about the effect of loop diuretics on mortality and serious adverse events in adult ICU patients with fluid overload. Loop diuretics may reduce the occurrence of these outcomes, but large randomised placebo-controlled trials at low risk of bias are needed.

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Use of diuretics in shock: Temporal trends and clinical impacts in a propensity-matched cohort study

Cited by 8 publications

References 34 publications

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

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

Association Between Furosemide Exposure and Clinical Outcomes in a Retrospective Cohort of Critically Ill Children

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

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