The most appropriate fluid-management strategy is to titrate this patient's fluid volume to a central venous pressure (CVP) of 4 mm Hg or less. This patient has acute respiratory distress syndrome (ARDS). A large multicenter trial has shown that a conservative fluid strategy leads to discontinuing mechanical ventilation sooner than the traditional or “liberal” fluid strategy. Limiting intravenous fluids and using diuretics to keep CVPs at lower targets has been associated with a more rapid improvement in lung function, shorter duration of mechanical ventilation, and shorter ICU length of stay. However, the study did not show an effect on mortality. The target CVP for the conservative strategy was 4 mm Hg.

A CVP target of 12 mm Hg would be more consistent with the “liberal” fluid management arm of the study, which was associated with longer duration of ventilation and is therefore not recommended.

Traditionally, a pulmonary artery catheter had been used to guide hemodynamic resuscitation; however, at least four international studies have shown that neither pulmonary artery catheters nor specific protocols that incorporate data from such catheters yield superior outcomes in most patients. In addition, these catheters have more risk associated with their use compared with a simple central line.