It is unclear whether fluid management goals are best achieved by bolus injection or continuous infusion of loop diuretics. In this study, we compared the effectiveness and safety of a continuous infusion with that of a bolus injection when an increased loop diuretic dosage is required in intensive care unit (ICU) patients.
We obtained data from the MIMIC-III database for patients who were first-time ICU admissions and required an increased diuretic dosage. Patients were excluded if they had an estimated glomerular filtration rate <15 ml/min/1.73 m 2 , were receiving renal replacement therapy, had a baseline systolic blood pressure <80 mmHg, or required a furosemide dose <120 mg. The patients were divided into a continuous group and a bolus group. Propensity score matching was used to balance patients’ background characteristics.
The final dataset included 807 patients (continuous group, n = 409; bolus group, n = 398). After propensity score matching, there were 253 patients in the bolus group and 231 in the continuous group. The 24 h urine output per 40 mg of furosemide was significantly greater in the continuous group than in the bolus group (234.66 ml [95% confidence interval (CI) 152.13–317.18, p < 0.01]). There was no significant between-group difference in the incidence of acute kidney injury (odds ratio 0.96, 95% CI 0.66–1.41, p = 0.85).
Our results indicate that a continuous infusion of loop diuretics may be more effective than a bolus injection and does not increase the risk of acute kidney injury in patients who need an increased diuretic dosage in the ICU.
Fluid overload is common in patients who are critically ill,
and several studies have demonstrated a correlation between fluid overload and adverse outcomes. , Conservative fluid management can improve the oxygenation index, increase the number of ventilator-free days, and shorten the stay in the intensive care unit (ICU). Loop diuretics administration is a well-established therapy that can decrease the incidence of fluid overload. Continuous infusion and bolus injection of diuretics are two methods that physicians can use to achieve their fluid management goals. However, there is still not enough evidence to indicate which strategy is better in terms of safety and efficiency. The randomized controlled Diuretic Optimization Strategies Evaluation in Acute Heart Failure (DOSE) study found no significant difference in patients’ global assessment of symptoms or in the change in renal function in a large group of patients with decompensated heart failure, when diuretics were administered by bolus as compared with continuous infusion. Other randomized controlled trials have yielded conflicting results in patients with heart failure. However, most of the studies only enrolled outpatients, who were very different from patients in the ICU. A recent meta-analysis reported that the beneficial effect on total urine output was greater when continuous furosemide was administered than when a bolus injection was delivered.
However, most of the randomized controlled trials included in that meta-analysis had small sample sizes.
Patients in the ICU have a high incidence of acute kidney injury (AKI) and are more vulnerable and more complicated to manage than the patients in a general medicine ward or outpatient. An appropriate diuretic strategy is needed to help physicians achieve their fluid management goals when a patient needs an increased dose of diuretics. The aim of this study was to compare the efficiency and safety of two diuretic strategies in a relatively large sample of patients who were admitted to the ICU based on the Medical Information Mart for Intensive Care (MIMIC)-III database.