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.

中文翻译：

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袢利尿剂在成人重症监护患者液体超负荷中的应用：通过荟萃分析和试验序贯分析对随机临床试验进行系统评价

背景

液体超负荷是重症监护病房 (ICU) 患者器官功能障碍和死亡的危险因素，但尚无其管理指南。我们系统地回顾了单袢利尿剂的益处和危害，单袢利尿剂是这些患者液体超负荷的主要治疗方法。

方法

我们遵循我们发布的方案、Cochrane 手册和 PRISMA 声明，对随机临床试验中报告的单袢利尿剂与其他干预措施进行了荟萃分析和试验序贯分析 (TSA) 的系统评价。我们使用 ROB2 工具评估偏倚风险，并使用 GRADE 评估证据的确定性。这项研究已在国际前瞻性系统评价登记册 (PROSPERO) 中注册 (CRD42020184799)。

结果

我们纳入了 10 项试验（804 名受试者），所有试验总体上都存在较高的偏倚风险。对于袢利尿剂与安慰剂/不干预，我们发现全因死亡率没有差异（相对风险 (RR) 0.72，95% 置信区间 (CI) 0.49–1.06；4 项试验；359 名受试者；I 2 = 0 ^%  ； TSA 调整 CI 0.15-3.48；证据质量非常低）。 尽管受到 TSA 的质疑（^TSA-调整 CI 0.55–1.20）。

结论

关于袢利尿剂对液体超负荷成人 ICU 患者死亡率和严重不良事件的影响，证据非常不确定。袢利尿剂可能会减少这些结果的发生，但需要低偏倚风险的大型随机安慰剂对照试验。