Abstract
Fluid overload is common among critically ill patients and is associated with worse outcomes. We aimed to assess the effect of diuretics on urine output, vasopressor dose, acute kidney injury (AKI) incidence, and need for renal replacement therapies (RRT) among patients who receive vasopressors. This is a single-center retrospective study of all adult patients admitted to the intensive care unit between January 2006 and December 2016 and received >6 hours of vasopressor therapy and at least one concomitant dose of diuretic. We excluded patients from cardiac care units. Hourly urine output and vasopressor dose for 6 hours before and after the first dose of diuretic therapy was compared. Rates of AKI development and RRT initiation were assessed with a propensity-matched cohort of patients who received vasopressors but did not receive diuretics. There was an increasing trend of prescribing diuretics in patients receiving vasopressors over the course of the study. We included 939 patients with median (IQR) age of 68(57, 78) years old and 400 (43%) female. The average hourly urine output during the first six hours following time zero in comparison with average hourly urine output during the six hours prior to time zero was significantly higher in diuretic group in comparison with patients who did not receive diuretics [81 (95% CI 73-89) ml/h vs. 42 (95% CI 39-45) ml/h, respectively; p<0.001]. After propensity matching, the rate of AKI within 7 days of exposure and the need for RRT were similar between the study and matched control patients (66 (15.6%) vs. 83 (19.6%), p = 0.11, and 34 (8.0%) vs. 37 (8.7%), p = 0.69, respectively). Mortality, however, was higher in the group that received diuretics. Ninety-day mortality was 191 (45.2%) in the exposed group VS 156 (36.9%) p = .009. While the use of diuretic therapy in critically ill patients receiving vasopressor infusions augmented urine output, it was not associated with higher vasopressor requirements, AKI incidence, and need for renal replacement therapy.
Highlights
Fluid management is one of the cornerstones of critically ill patient’s management [1, 2]
The average hourly urine output during the first six hours following time zero in comparison with average hourly urine output during the six hours prior to time zero was significantly higher in diuretic group in comparison with patients who did not receive diuretics [81 ml/h vs. 42 ml/h, respectively; p
While the use of diuretic therapy in critically ill patients receiving vasopressor infusions augmented urine output, it was not associated with higher vasopressor requirements, acute kidney injury (AKI) incidence, and need for renal replacement therapy
Summary
Fluid management is one of the cornerstones of critically ill patient’s management [1, 2]. Fluid resuscitation has been shown to improve outcomes in critically ill patients [2]. The spectrum of volume management in critically ill patients has been described in four distinct stages starting with resuscitation or salvage phase focusing on maintaining perfusion and cardiac output, followed by the optimization phase which uses targeted fluid therapy to improve oxygen delivery, a stabilization phase with a focus on preventing further organ damage, and lastly the de-escalation phase where patients are weaned off support and achieve negative fluid balance [3,4,5]. Over two-thirds of critically ill patients qualify the definition of volume overload (i.e., increase the weight more than 10% of admission body weight) in their first day of intensive care unit (ICU) stay [6], and most patients will be discharged from ICU while volume overloaded [7]. Fluid overload was correlated with an increased need for medical interventions [6], including the need for renal replacement therapy, mechanical ventilation [9], and decreased mobility [7]
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