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

Brittany D Bissell,Javier A Neyra,Alexander H Flannery,Peter E Morris,Melanie E Laine,Jeremy Riser,Melissa L Thompson Bastin,Jordan Potter,Andrew Kelly

doi:10.1186/s13054-020-2795-9

Abstract

ObjectiveAdministration 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.MethodsThis 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.ResultsA 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.ConclusionsThis 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.

Highlights

Intravenous (IV) fluid resuscitation is a necessary tool to improve hemodynamic stability and organ perfusion and possibly decrease mortality in critically ill patients admitted to the intensive care unit (ICU) [1, 2]
We aimed to evaluate the impact of a novel diuresis protocol utilizing common bedside monitoring parameters and simplified loop diuretic dosing on cumulative fluid balance over the first 72 h following hemodynamic stability, as compared to standard of care
In order to approximate an experimental design using observational electronic health record (EHR) data, each patient visit within the intervention group was matched to three patient visits meeting the above inclusion and exclusion criteria from the historical time period of all Medical ICU admits between January 2016 and December 2017 who received furosemide

Summary

Introduction

Intravenous (IV) fluid resuscitation is a necessary tool to improve hemodynamic stability and organ perfusion and possibly decrease mortality in critically ill patients admitted to the intensive care unit (ICU) [1, 2]. The benefit of continued fluid administration after the first 24–48 h is unclear. A positive fluid balance secondary to excess fluid accumulation has been associated with diverse and persistent detriment on a multitude of organ systems [3]. One approach to correcting fluid balance is shifting focus onto the post- or de-resuscitation period with appropriate diuresis, or renal replacement therapy (RRT) in those non-responsive to diuresis, once hemodynamic stability is achieved [5]. An overall lack of standardization exists in identification of fluid-overloaded patients as optimal transition times between fluid resuscitation and fluid

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Conclusion