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.

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方案化利尿对重症监护病房复苏的影响

目的 利尿剂的使用已被证明有助于液体管理并改善危重病休克后的临床结果。目前的指南尚未包括危重患者基于利尿剂的复苏的标准化或指导。本研究旨在评估多学科方案对危重病人利尿引导的复苏的影响。方法 这是在大型学术医疗中心的医疗重症监护病房 (ICU) 内进行的事前单中心试点研究。入住内科 ICU 接受机械通气的成年患者符合以下任一条件：(1) 通过胸片或体格检查发现容量超负荷的临床体征，或 (2) 自入院以来任何累积液体平衡≥ 0 mL 均符合纳入标准。患者根据临床医生的判断接受了为期 2 年的利尿（历史对照），然后是为期 1 年的利尿方案（干预）。干预组中的患者与符合研究纳入和排除标准的历史队列中的患者按 1:3 的比例匹配。结果共纳入364例患者，方案组91例，标准治疗273例。方案化利尿与休克后 72 小时累积体液平衡显着降低有关 [中位数，IQR - 2257 (- 5676-920) mL 对 265 (- 2283-3025) mL；p < 0.0001]。与历史组相比，干预组的院内死亡率较低（5.5% 对 16.1%；p = 0.008）和更高的无 ICU 天数（p = 0.03）。然而，在不使用呼吸机的天数中没有发现统计学上的显着差异，并且证明了高钠血症和低钾血症的发生率增加。结论 本研究表明，用于复苏的利尿方案可以显着改善休克后 72 小时的液体平衡，对临床结果具有潜在益处。