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Fluid Restriction and Edema Clearance

Practical Considerations

Recovery from ARDS requires that the pulmonary edema resolves [66, 67]. The primary methods to decrease pulmonary edema are the use of loop diuretics, such as furosemide and/or hemofiltration. The inherent risk of these methods is the induction of organ hypoperfusion. Monitoring strategies to guide the edema clearance by furosemide or hemofiltration before inducing organ hypoperfusion should be beneficial for outcomes, although data to support this assertion is limited. Recently the E/Ea ratio, an ultrasound-derived marker of left ventricular filling pressure, has been reported to be a discriminating factor for identifying ARDS patients who will not tolerate negative fluid balance [68]. The FACTT trial demonstrated that for patients with ARDS that are not in shock, adopting a conservative fluid management strategy improves pulmonary-related outcome. However, despite the benefit, the FACTT protocol was complex and practically difficult to implement in routine clinical practice. The protocol contained a total of 18 different cells with

Table 8.1 Simplified fluid and catheter treatment trial “FACTT Lite” protocol3

Central venous pressure

Urine output <0.5 mL/kg/h

Urine output >0.5 mL/kg/h

>8

Furosemideb

Furosemidec

4-8

Fluid bolusb

Furosemidec

<4

Fluid bolusb

No interventionc

Adapted from Grissom et al. [69]

“Recommended for patients with mean arterial pressure >60 mmHg and off vasopressors for >12 h bReassess in 1 h cReassess in 4 h

instructions that include dobutamine infusion, fluid bolus, or furosemide administration. To more easily operationalize a fluid restrictive strategy in subsequent trials, the ARDS Network investigators developed a simplified conservative fluid protocol, “FACTT Lite” (Table 8.1) [69]. The FACTT Lite provided three possible instructions determined by the CVP and urine output: furosemide administration, fluid bolus, or no intervention. As with the original FACTT Conservative protocol, FACTT Lite contained instructions to withhold furosemide until the patient achieved a mean arterial pressure greater than 60 mmHg off of vasopressors for at least 12 h.

A retrospective comparison of the performance of FACTT Lite with FACTT Conservative and FACTT Liberal was recently reported. Fluid management with FACTT Lite resulted in a significantly greater average cumulative fluid balance (+2.05 L) over 7 days than FACTT Conservative but a significantly lower average cumulative fluid balance compared to FACTT Liberal (+5.07 L mL) over the same time period. In subjects without baseline shock, in whom the fluid protocol was applied throughout the duration of the study, management with FACTT Lite resulted in an equivalent cumulative fluid balance to FACTT Conservative and had similar clinical outcomes of ventilator-free days, ICU-free days, and mortality as FACTT Conservative and significantly greater ventilator-free days and ICU-free days than FACTT Liberal. Interestingly, development of new-onset shock during the study was lower in the FACTT Lite group than in the FACTT Conservative group. This might be explained by a less aggressive diuresis in the first 2 days in the FACTT Lite group compared with the FACTT Conservative group.

 
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