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Critical Care Medicine

Answer 4
  1. Diuresis guided by a CVC to obtain the lowest right atrial pressure while maintaining adequate perfusion. In a randomized trial comparing 2 catheter strategies (CVC versus PAC) and 2 volume strategies (volume-liberal versus volume-conservative), researchers found no benefit and a potential increase in adverse events with the use of PAC.6 Therefore, PACs are not recommended for the routine care of patients with ARDS. Comparing the volume strategies, there was a reduction in the number of days on the ventilator and a trend towards decreased mortality for patients whose volume strategy pursued aggressive diuresis to achieve a low intravascular volume once hemodynamically stable.7 It is recommended that hemodynamically stable patients with ARDS undergo aggressive diuresis to decrease edemagenesis. RBC transfusion may be associated with increased mortality in critically ill patients, and thus there is no recommendation to pursue high levels of hemoglobin for patients with ARDS.8

    6. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med 2006;354: 2213-24.

    7. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006;354:2564-75.

    8. Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group [published erratum appears in N Engl J Med 1999; 340:1056]. N Engl J Med 1999;340:409-17.

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