title: Goal-directed diuresis: A case - control study of continuous furosemide infusion in critically ill trauma patients.
abstract: BACKGROUND
  Excessive crystalloid administration is common and associated with negative outcomes in critically ill trauma patients. Continuous furosemide infusion (CFI) to remove excessive fluid has not been previously described in this population. We hypothesized that a goal-directed CFI is more effective for fluid removal than intermittent bolus injection (IBI) diuresis without excess incidence of hypokalemia or renal failure.
  
  
  METHODS
  CFI cases were prospectively enrolled between November 2011 and August 2012, and matched to historic IBI controls by age, gender, Injury Severity Score (ISS), and net fluid balance (NFB) at diuresis initiation. Paired and unpaired analyses were performed to compare groups. The primary endpoints were net fluid balance, potassium and creatinine levels. Secondary endpoints included intensive care unit (ICU) and hospital length of stay (LOS), ventilator-free days (VFD), and mortality.
  
  
  RESULTS
  55 patients were included, with 19 cases and 36 matched controls. Mean age was 54 years, mean ISS was 32.7, and mean initial NFB was +7.7 L. After one day of diuresis with CFI vs. IBI, net 24 h fluid balance was negative (-0.55 L vs. +0.43 L, P = 0.026) only for the CFI group, and there was no difference in potassium and creatinine levels. Cumulative furosemide dose (59.4mg vs. 25.4mg, P < 0.001) and urine output (4.2 L vs. 2.8 L, P < 0.001) were also significantly increased with CFI vs. IBI. There were no statistically significant differences in ICU LOS, hospital LOS, VFD, or mortality.
  
  
  CONCLUSIONS
  Compared to IBI, goal-directed diuresis by CFI is more successful in achieving net negative fluid balance in patients with fluid overload with no detrimental side effects on renal function or patient outcome.
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
authors.forename: Daniel Dante
authors.initials: DD
authors.lastname: Yeh
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
authors.forename: Gwendolyn M
authors.initials: GM
authors.lastname: Van Der Wilden
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
authors.forename: Catrina
authors.initials: C
authors.lastname: Cropano
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
authors.forename: David R
authors.initials: DR
authors.lastname: King
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
authors.forename: Marc
authors.initials: M
authors.lastname: De Moya
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Fagenholz
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
authors.forename: Haytham
authors.initials: H
authors.lastname: Kaafarani
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
authors.forename: Jarone
authors.initials: J
authors.lastname: Lee
authors.affiliation: Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
authors.forename: George
authors.initials: G
authors.lastname: Velmahos
keywords: Crystalloids; diuresis; furosemide; trauma