Hemodynamics and Extravascular Lung Water in Acute Lung Injury

Goal: Overall I/O net negative 50ml/hour

Initiation:

• Continuous IV furosemide at 3mg/hour or last known protocol specified dose
• Titrate up or down by 3mg/hour increments every hour as needed to establish diuresis goal
• Do not exceed 30mg/hour

Furosemide Bolus:

• If unable to establish adequate diuresis at maximum dose may attempt furosemide bolusing as follows
• By intravenous bolus give 30, then 60, then 80, and 120 mg - one bolus dose every hour until urine output results in 1 ml/kg PBW/hr net negative fluid balance per hour
• Bolusing trials may be done at will but total furosemide dose may not exceed 800mg/24hour period

15 ml/kg PBW crystalloid (round to nearest 250 ml) or 25 grams albumin as rapidly as possible. Used for patients with a measured CVP<8 or measured PaOP <12mmHg in addition to concurrent urine output of <0.5 ml/kg/hr

(may use any alone or in combination)

• Norepinephrine - 0.05mcg/kg/min - increase for effect not to exceed (NTE) 1mcg/kg/min.
• Vasopressin - 0.04 international units/hour
• Phenylephrine - 7mcg/min - may increase to for effect not to exceed 500mcg/min.
• Epinephrine - 1 mcg/min - may increase for effect not to exceed 20mcg/min.

Weaning: When MAP ≥ 60 mm/Hg on stable dose of vasopressor begin reduction of vasopressor by greater than or equal to 25% stabilizing dose at intervals ≤ 4 hours to maintain MAP ≥ 60 mm/Hg.

• Begin at 5mcg/kg/min and increase by 3 mcg/kg/min increments at 15 minute intervals until C.I. ≥ 2.5 or maximum dose of 20mcg/kg/min has been reached.
• Begin weaning 4 hours after low CI is reversed. Wean by ≥ 25% of the stabilizing dose at intervals of ≤ 4 hours to maintain hemodynamic algorithm goals.
• If patient is on dobutamine as a result of an earlier cell assignment, dobutamine should be ignored for the purpose of subsequent assignment, but should be continued to be weaned per protocol.

Used in patients with a measured cardiac index < 2.5

Concentrate all drips and nutrition in order to minimize fluid volume as much as possible. Intravenous fluid to be run at keep vein open rate.

EVLW arm: Patients with a MAP > 60 and off vasopressors for >12 hours, as well as patients with a measured cardiac index >2.5 that also have a measured GEDI > goal.

Withhold furosemide if:

• Significant hypokalemia (K+ <= 2.5 meq/L), or hypernatremia (Na+ >= 155 meq/L) occurs within last 12 hours may then be restarted if the prevailing condition no longer exists
• Dialysis dependence
• Oliguria (less than 0.5ml/kg/hour) with either creatinine > 3, or clinical suspicion of rapidly evolving ARF
• More than 800mg has been given in less then 24 hours
• Creatinine increases > 1.5 mg/dl in any 24 hour period

• Need for CVVHD or intermittent hemodialysis to be determined by treating clinicians.
• CVC arm: If fluid management to be accomplished with dialysis then fluid balance goals to be determined per clinicians.
• EVLW arm: Fluid balance as per algorithm
• When using intermittent HD it is recommended that no more than 2 liters net negative fluid is removed per dialysis session. Total fluid removal per run to be estimated by the clinicians to attain CVP or GEDI goals per algorithm.