Hemodynamics and Extravascular Lung Water in Acute Lung Injury
NCT ID: NCT00624650
Last Updated: 2019-09-10
Study Results
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View full resultsBasic Information
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COMPLETED
PHASE2
33 participants
INTERVENTIONAL
2008-02-29
2011-01-31
Brief Summary
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Detailed Description
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Conditions
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Study Design
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RANDOMIZED
PARALLEL
TREATMENT
SINGLE
Study Groups
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Modified FACTT (control)
The investigators control arm consists of a simplified algorithm for conservative management of fluids in patients with ALI, as to be published by the ARDSnet group, based on the protocol used in the FACTT trial. The protocol calls for strict adherence to ARDSnet ventilation, our weaning protocol and use of only select vasoactive, beta-adrenergic drugs as it is felt that variation in these treatments could seriously confound our results. Albuterol administration will not be permitted in the either arm except for life threatening bronchospasm not responsive to ipratropium. Ipratropium may be administered at the treating physician's discretion for bronchospasm. PiCCO's will be placed in each control patient and data recorded twice daily. The treating physician's will be blinded to this data.
Diuresis (furosemide) part I
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
Fluid Bolus (crystalloid or albumin)
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
Vasopressors (Norepinephrine, Vasopressin, Phenylephrine, Epinephrine)
(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.
Dobutamine
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.
Diuresis (furosemide) part II
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
Dialysis
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.
EVLW
When EVLW exceeds 9 ml/kg PBW the algorithmic treatment is begun and continued until EVLW ≤9 ml/kg PBW or extubation whichever comes first as tolerated (see figure 6). Furosemide and volume contraction are initiated when sufficient volumetric preload (GEDI) is available to enact volume contraction as a means to decrease measured EVLW without causing concomitant hypoperfusion. Fluid administration is also guided by changes in EVLW. An increase in EVLW \> 2ml/kg PBW as a result of fluid administration curtails any further fluid administration until the next scheduled measurement.
Our ultimate treatment goal is to maximally lower EVLW towards the normal range - thus improving lung mechanics and gas exchange - without causing concomitant hemodynamic compromise and end-organ injury. By doing so we feel this algorithmic, goal directed, therapeutic approach should improve outcome.
Diuresis (furosemide) part I
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
Fluid Bolus (crystalloid or albumin)
10 ml/kg PBW crystalloid (round to nearest 70ml) or 25 grams albumin as rapidly as possible.
Perform thermodilution immediately before and after and 60 minutes after each bolus. If EVLW increases \> 2ml/kg PBW within 60 minutes after a bolus do not give any further boluses until next regularly scheduled measurement. This therapy is available for patients with a map \< 60 or who are on vasopressors that also have a measured GEDI less than goal
Vasopressors (Norepinephrine, Vasopressin, Phenylephrine, Epinephrine)
(may use 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.
In the experimental arm vasopressors are a treatment option in patients with a Mean Arterial Pressure of \< 60
Dobutamine
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
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.
Diuresis (furosemide) part II
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
Dialysis
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.
Interventions
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Diuresis (furosemide) part I
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
Fluid Bolus (crystalloid or albumin)
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
Fluid Bolus (crystalloid or albumin)
10 ml/kg PBW crystalloid (round to nearest 70ml) or 25 grams albumin as rapidly as possible.
Perform thermodilution immediately before and after and 60 minutes after each bolus. If EVLW increases \> 2ml/kg PBW within 60 minutes after a bolus do not give any further boluses until next regularly scheduled measurement. This therapy is available for patients with a map \< 60 or who are on vasopressors that also have a measured GEDI less than goal
Vasopressors (Norepinephrine, Vasopressin, Phenylephrine, Epinephrine)
(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.
Vasopressors (Norepinephrine, Vasopressin, Phenylephrine, Epinephrine)
(may use 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.
In the experimental arm vasopressors are a treatment option in patients with a Mean Arterial Pressure of \< 60
Dobutamine
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
Dobutamine
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.
Concentrate all drips and nutrition
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.
Diuresis (furosemide) part II
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
Dialysis
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.
Eligibility Criteria
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Inclusion Criteria
1. PaO2/FiO2 less than or equal to 300.
2. Bilateral infiltrates consistent with pulmonary edema on the frontal chest radiograph.
3. Requirement for positive pressure ventilation through an endotracheal tube or tracheostomy.
4. No clinical evidence of left atrial hypertension that would explain the pulmonary infiltrates. If measured, pulmonary arterial wedge pressure less than or equal to 18 mmHg.
3. Neuromuscular disease that impairs ability to ventilate without assistance, such as C5 or higher spinal cord injury, amyotrophic lateral sclerosis, Guillain-Barré syndrome, myasthenia gravis, or kyphoscoliosis (see Appendix I.A).
4. Pregnancy (negative pregnancy test required for women of child-bearing potential).
5. Severe chronic respiratory disease (see Appendix I.C).
6. Severe Chronic Liver Disease (Child-Pugh 11 - 15, see Appendix I.E)
7. Weight \> 160 kg.
8. Burns greater than 70% total body surface area.
9. Malignancy or other irreversible disease or conditions for which 6-month mortality is estimated to be greater than 50 % (see Appendix I.A).
10. Known cardiac or vascular aneurysm.
11. Contraindications to femoral arterial puncture - platelets \< 30, bilateral femoral arterial grafts, INR \> 3.0.
12. Not committed to full support.
13. Participation in other experimental medication trial within 30 days.
14. Allergy to intravenous lasix or any components of its carrier.
15. History of severe CHF - NYHA class ≥ III, previously documented EF \< 30%.
16. Diffuse alveolar hemorrhage.
17. Presence of reactive airway disease (active will be defined based on recent frequency and amounts of MDI's use and steroids to control the disease).
Exclusion Criteria
18 Years
ALL
No
Sponsors
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Pulsion Medical Systems
INDUSTRY
Oregon Clinical and Translational Research Institute
OTHER
Oregon Health and Science University
OTHER
Responsible Party
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Principal Investigators
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Charles Phillips, M.D.
Role: PRINCIPAL_INVESTIGATOR
Oregon Health and Science University
Locations
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Kaiser Permanente Sunnyside
Clackamas, Oregon, United States
Legacy Good Samaritan
Portland, Oregon, United States
Oregon Health and Science University
Portland, Oregon, United States
Countries
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References
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Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med. 2000 May 4;342(18):1334-49. doi: 10.1056/NEJM200005043421806. No abstract available.
Matthay MA. Alveolar fluid clearance in patients with ARDS: does it make a difference? Chest. 2002 Dec;122(6 Suppl):340S-343S. doi: 10.1378/chest.122.6_suppl.340s.
Mitchell JP, Schuller D, Calandrino FS, Schuster DP. Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization. Am Rev Respir Dis. 1992 May;145(5):990-8. doi: 10.1164/ajrccm/145.5.990.
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National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network; Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006 Jun 15;354(24):2564-75. doi: 10.1056/NEJMoa062200. Epub 2006 May 21.
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Phillips, C.R., Smith S. Extravascular Lung Water In Early ARDS ATS Poster Exhibit, 2006
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Other Identifiers
Review additional registry numbers or institutional identifiers associated with this trial.
IRB #e2978
Identifier Type: -
Identifier Source: secondary_id
IRB00003491
Identifier Type: -
Identifier Source: org_study_id
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