Fluid Management

Patients with ARDS in the setting of a positive fluid balance have an increased mortality.33 Thus, early and aggressive limitation of unnecessary volume infusion is encouraged by eliminating any “maintenance IV fluid,” maximally concentrating all necessary drips, and converting IV medications to enteral. If the patient’s hemodynamics can tolerate diuresis, this should be pushed aggressively.34 In the setting of hemodynamic compromise, attempts should be made to minimize volume and be judicious with any trials of diuresis. Some Role 3 facilities are equipped with Continuous Renal Replacement Therapy (CRRT) which can also be used to eliminate excess intravascular volume in the setting of poor renal function under the direction of an intensivist or nephrologist experienced in this therapy (See JTS Hyperkalemia and Dialysis in the Deployed Setting CPG35). If the patient is hypoproteinemic (i.e., total protein < 6 g/dL), albumin 25 g IV every 8 hours (100 mL 25% albumin) combined with diuresis for 3-5 days has been demonstrated to improve oxygenation and diuresis in two prospective randomized studies in patients with ARDS. The goals of therapy include a CVP < 4 mmHg with evidence of effective circulation by exam (warm, no mottling and capillary refill < 2 s) and adequate urine output (≥ 0.5 mL/kg/hr).12