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Ravi KS, Espersen C, Curtis KA, Cunningham JW, Jering KS, Prasad NG, Platz E, Mc Causland FR. Temporal Changes in Electrolytes, Acid-Base, QTc Duration, and Point-of-Care Ultrasound during Inpatient Hemodialysis Sessions. KIDNEY360 2022; 3:1217-1227. [PMID: 35919528 PMCID: PMC9337888 DOI: 10.34067/kid.0001652022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/09/2022] [Indexed: 02/02/2023]
Abstract
Background Of the more than 550,000 patients receiving maintenance hemodialysis (HD) in the United States, each has an average of 1.6 admissions annually (>880,000 inpatient HD sessions). Little is known about the temporal changes in laboratory values, ECGs, and intravascular and extravascular volume during inpatient HD sessions. Methods In this prospective cohort study of hospitalized HD patients, we assessed intradialytic laboratory values (metabolic panels, blood gases, ionized calcium levels), ECGs, and sonographic measures of volume status. Results Among 30 participants undergoing HD (mean age 62 years; 53% men, 43% Black) laboratory values had the largest changes in the first hour of HD. There was no significant change in ionized calcium levels pre- to post-HD (change: -0.01±0.07, P=0.24); 12 of 30 and 17 of 30 patients had levels below the lower reference limit at the beginning and end of HD, respectively. The mean pH increased pre- to post-HD (change: 0.06±0.04, P<0.001); 21 of 30 had a pH above the upper reference limit post-HD. There was a trend toward longer median QTc duration from pre- to post-HD (change: 7.5 msec [-5 msec, 19 msec], P=0.07). The sum of B lines on lung ultrasound decreased from pre- to post-HD (median decrease: 3 [1, 7], P<0.01). The collapsibility index of the inferior vena cava increased pre- to post-HD (median increase: 4.8% [1.5%, 13.4%], P=0.01), whereas internal jugular vein diameter did not change (P=0.24). Conclusions Among hospitalized patients undergoing HD, we found dynamic changes in laboratory values, QTc duration, and volume status. Further research is required to assess whether HD prescriptions can be tailored to alter these variations to potentially improve patient outcomes.
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Affiliation(s)
- Katherine Scovner Ravi
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Caroline Espersen
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,Cardiovascular Noninvasive Imaging Research Laboratory, Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Katherine A. Curtis
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Jonathan W. Cunningham
- Harvard Medical School, Boston, Massachusetts,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Karola S. Jering
- Harvard Medical School, Boston, Massachusetts,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Narayana G. Prasad
- Harvard Medical School, Boston, Massachusetts,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Elke Platz
- Harvard Medical School, Boston, Massachusetts,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Finnian R. Mc Causland
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
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Chaudhary R, Sukhi A, Simon MA, Villanueva FS, Pacella JJ. Role of Internal Jugular Venous Ultrasound in suspected or confirmed Heart Failure: A Systematic Review. J Card Fail 2021; 28:639-649. [PMID: 34419599 DOI: 10.1016/j.cardfail.2021.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Few data are available on the use of internal jugular vein (IJV) ultrasound parameters to assess central venous pressure and clinical outcomes among patients with suspected or confirmed heart failure (HF). METHODS We performed electronic searches on PubMed, The Cochrane Library, EMBASE, EBSCO, Web of Science, and CINAHL databases from the inception through January 9, 2021, to identify studies evaluating the accuracy and reliability of the IJV ultrasound parameters and exploring its correlation with central venous pressure and clinical outcomes in adult patients with suspected or confirmed acutely decompensated HF. The studies' report quality was assessed by Quality Assessment of Diagnostic Accuracy Studies-2 scale. RESULTS A total of 11 studies were eligible for final analysis (n = 1481 patients with HF). The studies were segregated into 3 groups: (1) the evaluation of patients presenting to the emergency department with dyspnea, (2) the evaluation of patients presenting to the HF clinic for follow-up, and (3) the evaluation of hospitalized patients with acutely decompensated HF or undergoing right heart catheterization. US parameters included IJV height, IJV diameter, IJV diameter ratio, IJV cross-sectional area, respiratory compressibility index, and compression compressibility index. CONCLUSIONS The findings of this systematic review suggest a significant role for ultrasound interrogation of the IJV in evaluation of patients in the emergency department presenting with dyspnea, in the outpatient clinic for poor clinical outcomes in HF, and in determining the timing of discharge for patients admitted with acutely decompensated HF. Further studies are warranted for testing the reliability of the reported ultrasound indices.
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Affiliation(s)
- Rahul Chaudhary
- UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania.
| | - Ajaypaul Sukhi
- Department of Cardiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Marc A Simon
- Department of Medicine, Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Flordeliza S Villanueva
- UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania; Center for Molecular Imaging & Image-Guided Therapeutics, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John J Pacella
- UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania; Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Pittsburgh, Pennsylvania; Department of Bioengineering, Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Blaivas M, Blaivas L, Philips G, Merchant R, Levy M, Abbasi A, Eickhoff C, Shapiro N, Corl K. Development of a Deep Learning Network to Classify Inferior Vena Cava Collapse to Predict Fluid Responsiveness. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1495-1504. [PMID: 33038035 DOI: 10.1002/jum.15527] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/09/2020] [Accepted: 09/14/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To create a deep learning algorithm capable of video classification, using a long short-term memory (LSTM) network, to analyze collapsibility of the inferior vena cava (IVC) to predict fluid responsiveness in critically ill patients. METHODS We used a data set of IVC ultrasound (US) videos to train the LSTM network. The data set was created from IVC US videos of spontaneously breathing critically ill patients undergoing intravenous fluid resuscitation as part of 2 prior prospective studies. We randomly selected 90% of the IVC videos to train the LSTM network and 10% of the videos to test the LSTM network's ability to predict fluid responsiveness. Fluid responsiveness was defined as a greater than 10% increase in the cardiac index after a 500-mL fluid bolus, as measured by bioreactance. RESULTS We analyzed 211 videos from 175 critically ill patients: 191 to train the LSTM network and 20 to test it. Using standard data augmentation techniques, we increased our sample size from 191 to 3820 videos. Of the 175 patients, 91 (52%) were fluid responders. The LSTM network was able to predict fluid responsiveness moderately well, with an area under the receiver operating characteristic curve of 0.70 (95% confidence interval [CI], 0.43-1.00), a positive likelihood ratio of infinity, and a negative likelihood ratio of 0.3 (95% CI, 0.12-0.77). In comparison, point-of-care US experts using video review offline and manual diameter measurement via software caliper tools achieved an area under the receiver operating characteristic curve of 0.94 (95% CI, 0.83-0.99). CONCLUSIONS We demonstrated that an LSTM network can be trained by using videos of IVC US to classify IVC collapse to predict fluid responsiveness. Our LSTM network performed moderately well given the small training cohort but worse than point-of-care US experts. Further training and testing of the LSTM network with a larger data sets is warranted.
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Affiliation(s)
- Michael Blaivas
- Department of Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA
- Department of Emergency Medicine, St Francis Hospital, Columbus, Georgia, USA
| | - Laura Blaivas
- Michigan State University, East Lansing, Michigan, USA
| | - Gary Philips
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio, USA
| | - Roland Merchant
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mitchell Levy
- Department of Medicine, Division of Pulmonary Critical Care and Sleep, Warren Alert Medical School of Brown University, Providence, Rhode Island, USA
| | - Adeel Abbasi
- Department of Medicine, Division of Pulmonary Critical Care and Sleep, Warren Alert Medical School of Brown University, Providence, Rhode Island, USA
| | - Carsten Eickhoff
- Brown Center for Biomedical Informatics, Brown University, Providence, Rhode Island, USA
| | - Nathan Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Keith Corl
- Department of Medicine, Division of Pulmonary Critical Care and Sleep, Warren Alert Medical School of Brown University, Providence, Rhode Island, USA
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4
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Clinical measurements obtained from point-of-care ultrasound images to assess acquisition skills. Ultrasound J 2019; 11:4. [PMID: 31359267 PMCID: PMC6638581 DOI: 10.1186/s13089-019-0119-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 02/14/2019] [Indexed: 11/10/2022] Open
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5
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Corl KA, Azab N, Nayeemuddin M, Schick A, Lopardo T, Zeba F, Phillips G, Baird G, Merchant RC, Levy MM, Blaivas M, Abbasi A. Performance of a 25% Inferior Vena Cava Collapsibility in Detecting Fluid Responsiveness When Assessed by Novice Versus Expert Physician Sonologists. J Intensive Care Med 2019; 35:1520-1528. [PMID: 31610729 DOI: 10.1177/0885066619881123] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Inferior vena cava collapsibility (cIVC) measured by point-of-care ultrasound (POCUS) has been proposed as a noninvasive means of assessing fluid responsiveness. We aimed to prospectively evaluate the performance of a 25% cIVC cutoff value to detect fluid responsiveness among spontaneously breathing intensive care unit (ICU) patients when assessed with POCUS by novice versus expert physician sonologists. METHODS Prospective observational study of spontaneously breathing ICU patients. Fluid responsiveness was defined as a >10% increase in cardiac index following a 500 mL fluid bolus, measured by bioreactance. Novice sonologist measured cIVC with POCUS. Their measurements were later compared to an expert physician sonologist who independently reviewed the POCUS images and assessed cIVCs. RESULTS Of the 85 participants, 44 (52%) were fluid responders. A 25% cIVC cutoff value performed better when assessed by expert sonologists than novice physician sonologists (receiver-operator characteristic curve, ROC = 0.82 [0.74-0.88] vs ROC = 0.69 [0.60-0.77]). CONCLUSIONS A 25% cIVC cutoff value measured by POCUS detects fluid responsiveness. However, the experience of the physician sonologist affects test performance and should be considered when interpreting and clinically using cIVC to direct intravenous fluid resuscitation.
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Affiliation(s)
- Keith A Corl
- Department of Medicine, 12321Alert Medical School of Brown University, Providence, RI, USA
| | - Nader Azab
- Department of Medicine, 12321Alert Medical School of Brown University, Providence, RI, USA
| | - Mohammed Nayeemuddin
- Department of Medicine, 12321Alert Medical School of Brown University, Providence, RI, USA
| | - Alexandra Schick
- Department of Emergency Medicine, 12321Alpert Medical School of Brown University, Providence, RI, USA
| | - Thomas Lopardo
- 12321Alpert Medical School of Brown University, the Brown University School of Public Health, Providence, RI, USA
| | - Fatima Zeba
- Department of Medicine, Kent Hospital, 12321Alpert Medical School of Brown University, Warwick, RI, USA
| | - Gary Phillips
- Center for Biostatistics, Department of Biomedical Informatics, Ohio State University, Columbus, Ohio, USA
| | - Grayson Baird
- Lifespan Biostatistics Core, Rhode Island Hospital, Providence, RI, USA
| | - Roland C Merchant
- 6752Brown University School of Public Health, Providence, RI, USA.,Department of Emergency Medicine, 1861Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mitchell M Levy
- Department of Medicine, 12321Alert Medical School of Brown University, Providence, RI, USA
| | - Michael Blaivas
- Department of Emergency Medicine, St Francis Hospital, 2629University of South Carolina School of Medicine, Columbus, SC, USA
| | - Adeel Abbasi
- Department of Medicine, 12321Alert Medical School of Brown University, Providence, RI, USA.,6752Brown University School of Public Health, Providence, RI, USA
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Lucas BP, D'Addio A, Block C, Manning H, Remillard B, Leiter JC. Limited agreement between two noninvasive measurements of blood volume during fluid removal: ultrasound of inferior vena cava and finger-clip spectrophotometry of hemoglobin concentration. Physiol Meas 2019; 40:065003. [PMID: 31091520 DOI: 10.1088/1361-6579/ab21af] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Plots of blood volume measurements over time (profiles) may identify euvolemia during fluid removal for acute heart failure. We assessed agreement between two noninvasive measurements of blood volume profiles during mechanical fluid removal, which exemplifies the interstitial fluid shifts that occur during diuretic-induced fluid removal. APPROACH During hemodialysis we compared change in maximum diameter of the inferior vena cava by ultrasound ([Formula: see text]) to change in relative blood volume derived from capillary hemoglobin concentration from finger-clip spectrophotometry (RBVSpHb). We grouped profiles of these measurements into three distinct shapes using an unbiased, data-driven modeling technique. METHODS Fifty patients who were not in acute heart failure underwent a mean of five paired measurements while an average of 1.3 liters of fluid was removed over 2 h during single hemodialysis sessions. [Formula: see text] changed -1.0 mm (95% CI -1.9 to -0.2 mm) and the RBVSpHb changed -1.1% (95% CI -2.7 to +0.5%), but these changes were not correlated (r -0.04, 95% CI -0.32 to +0.24). Nor was there agreement between categorization of profiles of change in the two measurements (kappa -0.1, 95% CI -0.3 to +0.1). SIGNIFICANCE [Formula: see text] and RBVSpHb estimates of blood volume do not agree during mechanical fluid removal, likely because regional changes in blood flow and pressure modify IVC dimensions as well as changes total blood volume.
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Affiliation(s)
- Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, VT, United States of America. Geisel School of Medicine at Dartmouth College, Hanover, NH, United States of America. Author to whom any correspondence should be addressed. White River Junction VA Medical Center, 215 N Main Street, White River Junction, VT, United States of America
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