Hemodynamics and Extravascular Lung Water in Acute Lung Injury

Goal: Overall I/O net negative 50ml/hour Initiation: 1. Continuous IV furosemide at 3mg/hour or last known protocol specified dose 2. Titrate up or down by 3mg/hour increments every hour as needed to establish diuresis goal 3. Do not exceed 30mg/hour Furosemide Bolus: 1. If unable to establish adequate diuresis at maximum dose may attempt furosemide bolusing as follows 2. 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 3. 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) 1. Norepinephrine - 0.05mcg/kg/min - increase for effect not to exceed (NTE) 1mcg/kg/min. 2. Vasopressin - 0.04 international units/hour 3. Phenylephrine - 7mcg/min - may increase to for effect not to exceed 500mcg/min. 4. 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.

1. 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. 2. 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. 3. 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: 1. 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 2. Dialysis dependence 3. Oliguria (less than 0.5ml/kg/hour) with either creatinine \> 3, or clinical suspicion of rapidly evolving ARF 4. More than 800mg has been given in less then 24 hours 5. Creatinine increases \> 1.5 mg/dl in any 24 hour period

1. Need for CVVHD or intermittent hemodialysis to be determined by treating clinicians. 2. CVC arm: If fluid management to be accomplished with dialysis then fluid balance goals to be determined per clinicians. 3. EVLW arm: Fluid balance as per algorithm 4. 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.