Study: NCT00624650

Intervention type: DRUG
Group type: EXPERIMENTAL
Intervention: Diuresis (furosemide) part I
Description: 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

Intervention type: DRUG
Group type: ACTIVE_COMPARATOR
Intervention: Diuresis (furosemide) part I
Description: 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

Intervention type: OTHER
Group type: ACTIVE_COMPARATOR
Intervention: Fluid Bolus (crystalloid or albumin)
Description: 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

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Fluid Bolus (crystalloid or albumin)
Description: 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

Intervention type: DRUG
Group type: ACTIVE_COMPARATOR
Intervention: Vasopressors (Norepinephrine, Vasopressin, Phenylephrine, Epinephrine)
Description: (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.

Intervention type: DRUG
Group type: EXPERIMENTAL
Intervention: Vasopressors (Norepinephrine, Vasopressin, Phenylephrine, Epinephrine)
Description: (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

Intervention type: DRUG
Group type: EXPERIMENTAL
Intervention: Dobutamine
Description: 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

Intervention type: DRUG
Group type: ACTIVE_COMPARATOR
Intervention: Dobutamine
Description: 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.

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Concentrate all drips and nutrition
Description: 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.