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If the fluid challenges have been given, and there has been no response to the frusemide, the next stage is to site a central venous line to get a clear idea of what is actually going on - ie has the patient been adequately rehydrated, are they in heart failure, etc. The column of fluid is lined up with the sternal notch or mid axillary point; the normal value is anywhere from 0 to 6cm. The physician is looking for some sort of response to a fluid challenge, interpreted as follows:-
The patient should be resuscitated accordingly.
The next step from here is a renal dose of dopamine - 2 to 5 micrograms per kg per minute; at this dose it is a specific renal vasodilator.