Table 3.

Stepped Pharmacologic Care Treatment Algorithm

Urine output (UO) goals to be assessed daily from randomization to 96 hours

UO > 5 L/d → Reduce current diuretic regimen if desired

UO 3–5 L/d → Continue current diuretic regimen

UO < 3 L/d → See diuretic grid

24-hour assessment

UO recommendations as above

Advance to next step on grid if UO < 3 L/d

48-hour assessment

UO recommendations as above

Advance to next step on grid if UO < 3 L/d

Consider dopamine or dobutamine at 2 μg/kg/h if SBP < 110 mm Hg and EF <40% or RV systolic dysfunction.

Consider nitroglycerin or nesiritide if SBP > 120 mm Hg (any EF) and severe symptoms

72- and 96-hour assessments

UO recommendations as above

Advance to next step on grid if UO < 3 L/d

Consider dopamine or dobutamine at 2 μg/kg/hr if SBP < 110 mm Hg and EF <40% or RV systolic dysfunction.

Consider nitroglycerin or nesiritide if SBP > 120 mm Hg (any EF) and severe symptoms

Consider hemodynamic guided IV therapy, LVAD, dialysis, or ultrafiltration crossover

Diuretic Grid
		Suggested Dose
Current Dose		Daily Loop Dose	Thiazide
A	<80 mg	40 mg IV bolus + 5 mg/h	None
B	81–160 mg	80 mg IV bolus + 10 mg/h	5 mg metolazone once daily
C	161–240 mg	80 mg IV bolus + 20 mg/h	5 mg metolazone twice daily
D	>240mg	80 mg IV bolus + 30 mg/h	5 mg metolazone twice daily

SBP, systolic blood pressure; EF, ejection fraction; RV, right ventricle; LVAD, left ventricular assist device; Loop, loop diuretic dose in furosemide equivalents.