DIURETIC MANAGEMENT IN CRITICALLY ILL PATIENTS IN THE INTENSIVE CARE UNIT: A LITERATURE REVIEW

Abstract

Background: Critically ill patients in the intensive care unit (ICU) frequently experience pathological fluid overload (FO) following aggressive fluid resuscitation, which is strongly associated with increased morbidity and mortality. Loop diuretics, especially furosemide, remain the cornerstone of decongestive therapy. However, their use in critical illness is complex due to patient response heterogeneity and the risk of organ complications. Objective: This literature review aims to comprehensively outline the clinical physiology, pathophysiology, pharmacological classification, and practical strategies for the administration and monitoring of diuretic therapy in critically ill patients. Methods: A comprehensive literature search was conducted across PubMed, ScienceDirect, and Google Scholar for scientific articles, clinical trials, and guidelines relevant to diuretic management in critically ill patients published between 2017 and 2025. Results:Persistent fluid overload worsens pulmonary edema (ARDS) and decreases the renal perfusion gradient due to systemic venous congestion, contributing to acute kidney injury (AKI). Loop diuretics act on the thick ascending limb of the loop of Henle, providing rapid onset when administered intravenously. To overcome diuretic resistance, sequential nephron blockade using thiazides or acetazolamide combinations can be utilized. Functional monitoring using the Furosemide Stress Test (FST) and Point-of-Care ultrasound (POCUS/VExUS) helps assess systemic venous congestion dynamically. Diuretics do not directly cure kidney injury; rather, they are used to manage volume overload in accordance with KDIGO recommendations. Conclusion: Diuretic management in critically ill patients must be individualized through multiparametric evaluation to balance organ decongestion benefits against risks of electrolyte imbalances, metabolic alkalosis, and hemodynamic instability.