Footnotes_v6-clarified5-1-04.doc

B. Footnotes, Version VI (Clarified)

A. Dobutamine:
1. Start at 5 mcg/kg/min and increase by 5 mcg/kg/min
increments at 15 minute intervals until ineffective circulation
reversed (CI greater than or equal to 2.5 for PAC or fewer than
3 physical findings of ineffective circulation for CVP) or
maximum dose of 20 mcg/kg/min reached.
2. Begin weaning 4 hours after ineffective circulation is reversed.
Wean by greater than or equal to 25% of the stabilizing dose at
intervals of less than or equal to 4 hours to maintain effective
circulation
3. If a patient is on dobutamine as a result of an earlier cell
assignment, dobutamine should be ignored for the purpose of
subsequent cell assignment, but should continue to be weaned
per protocol.
B. Furosemide
If the protocol instructs the use of furosemide, and furosemide is unavailable, then bumetanide should be substituted for furosemide, with a dose equivalency ratio of 40:1 (40mg of furosemide = 1 mg of bumetanide). As the protocol allows with furosemide, bumetanide can be delivered either via bolus or continuous infusion at the discretion of the physicians caring for the patient. If and when furosemide becomes available again, furosemide should be utilized to carry out protocol instructions.
1. Withhold if:
a. vasopressor or a fluid bolus given last 12 hours OR
b. renal failure present (dialysis dependence)* OR

c. oliguria with creatinine >3, OR
d. oliguria with creatinine 0-3 and urinary studies indicative of
acute renal failure.
2. For cells 3, 7, and 8:
Begin continuous infusion of 3 mg/hour OR 20 mg bolus OR
last known protocol specified effective dose. Reassess in 1 hour.
Double dose hourly until urine output is greater than or equal to
0.5 ml/kg/hour OR maximum infusion of 24 mg/hour or ma ximum
Clarified-Footnotes v6 to FACTT Protocol v2 ARDSNet Rev. May 1, 2004 bolus of 160 mg is reached. Discontinue furosemide if no response
to maximum dose after 1 hour.
3. For cells 11, 15, 16, 18:
Begin continuous infusion of 3 mg/hour OR 20 mg bolus OR
last known protocol specified effective dose. Reassess in 4 hours; if still in a cell
for which furosemide is indicated then:
a. If intravascular pressure has declined by one or more
pressure ranges (rows) repeat the same dose as before, and
then reassess in 4 hours.
b. If intravascular pressure range has not declined by one or
more pressure ranges (rows), and if average urine output
over the preceding four hours is less than or equal to
3ml/kg/hr, double the preceding dose and reassess in 4
hours. If average urine output over the preceding four hours
is greater than 3ml/kg/hr, then give the same dose as
before and reassess within four hours. Maximum daily
infusion dose = 24 mg/hour x 12 hours (3 four hour cycles);
maximum bolus dose = 160 mg q 4 hours x 3 doses.
4. If either the maximum daily infusion (24mg/hr x 12 hrs) or
maximum bolus dose sequence (160 mg x 3) is given, then
do not give additional furosemide doses for 12 hours
following the end of the 12 hour infusion or for 12 hours
after the third 160 mg bolus.
. If at least one cell has passed that does NOT call for Lasix to
be given, or at least 12 hours has passed from a sequence of
maximum furosemide dosing, you can either start back at 20
mg, give the last known effective dose, or give any dose in
between (as determined by the ICU team).
C. Fluid Bolus (Non-shock, except cell #19):
1. Administer 15 ml/kg PBW normal saline, Plasmalyte, or
Ringer's lactate (rounded to the NEAREST 250 cc) or 1 unit
of RBCs or 25 grams albumin (choice at discretion of physician)
over less than or equal to 1 hour then reassess patient . For
cells 5,6,9,10, reassess within one hour. For cells 13,14,19, reassess
within four hours. Administer up to 3 boluses over 24 hours if
indicated by protocol. This 24 hour period begins with the first
protocol- mandated non-shock bolus OR the first
protocol- mandated bolus following shock reversal.
Clarified-Footnotes v6 to FACTT Protocol v2 ARDSNet Rev. May 5,2004 2. Additional fluid boluses are allowed at the discretion of the physician. D. Fluid Bolus (Cell #19 only): 1. Withhold fluid bolus if: Cardiac index (CI) is greater than or equal to 4.5 OR FiO2 is greater than or equal to 0.7.
2. Use 15 ml/kg PBW normal saline, Plasmalyte, or Ringer's
lactate (rounded to the NEAREST 250 cc) or 1 unit of RBCs
or 25 grams albumin (physicians discretion) over less than or
equal to 1 hour then reassess patient within 4 hours. Administer up to 3 boluses
over 24 hours if indicated by protocol. This 24 hour period
begins with the first protocol- mandated non-shock bolus OR
the first protocol- mandated bolus following shock reversal.
3. Additional fluid boluses are allowed at the discretion of the
physician.
E. KVO IV:
1. Also minimize as much as possible all other fluid volume (e.g.,
for delivery of antibiotics etc.), except as required for nutrition
support.
F. Guidelines for Management of Shock:
§ Shock is defined as a MAP < 60 mmHg or a MAP > 60 while receiving § Assessments during shock should be recorded at least every 4 hours and at the time of each new entry or exit from a shock cell (cells 1 and 2). § Physicians have the choice of either fluid bolus and/or vasopressor therapy (in 1. Fluid Bolus (Shock):
Use 15 ml/kg PBW normal saline, Plasmalyte, or Ringers
(rounded to the NEAREST 250 cc) or 1 unit of RBCs or 25
grams albumin (physicians discretion) over less than or equal to
1 hour then reassess patient.
2. Vasopressor Therapy:
Choice of any single agent or any combination of the following:
a. Dopamine 5 mcg/kg/min, increase to a maximum of 25
mcg/kg/min.
b. Norepinephrine at 1 mcg/min, increase to a maximum of
100 mcg/min.
Clarified-Footnotes v6 to FACTT Protocol v2 ARDSNet Rev. May 5,2004 c. Epinephrine at 1 mcg/min, increase to a maximum of 20 mcg/min. d. Phenylephrine at 10 mcg/min, increase to a maximum of 500 mcg/min. e. Intravenous Vasopressin 0.005-0.04 international units/minute
3. Vasopressor Weaning (includes any dose of dopamine):
a. When MAP > 60 mmHg on a stable dose of vasopressor,
begin reduction of the vasopressor by greater than or equal
to 25% of the stabilizing dose at intervals of less than or equal
to 4 hours to maintain MAP greater than or equal to 60 mmHg.
b. Dopamine is considered "discontinued" for vasopressor use
and cell assignment when it is weaned to less than or equal
to 5 mcg/kg/min, but should continue to be weaned per protocol
(footnote F.3.a. above).
G. Invalid PAOP
1. If a valid PAOP measurement cannot be obtained, use the
pulmonary artery diastolic pressure to estimate the PAOP,
based upon the most recently available relationship between
PAOP and PADP, and assuming a stable arithmetic difference
between the two values. For example, if the most recent prior
valid measurements showed a PAOP = 10 and a PADP = 15,
and the current PADP = 20 and a valid PAOP cannot be
obtained, then assume a current PAOP = 15.
2. If neither a valid PAOP nor PADP can be obtained, then utilize
the current CVP value.
* Renal Failure
a. Dialysis dependence is defined as the period from the initiation
of dialysis to the time that continuous dialysis is discontinued or
to the time following the last session of intermittent dialysis.
b. During this period of dialysis dependence, urine output is
considered to be adequate for the purposes of cell assignment.
Clarified-Footnotes v6 to FACTT Protocol v2 ARDSNet Rev. May 5,2004

Source: http://www.ardsnet.org/system/files/footnotes_v6-clarified_2004-05-01_0.pdf