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Jefferies JL, Stavish CA, Silver MA, Butler J, Humes HD, Strobeck J. Blood Volume Analysis and Cardiorenal Syndrome: From Bench to Bedside. Cardiorenal Med 2024; 14:483-497. [PMID: 39033745 DOI: 10.1159/000540497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 05/09/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND This review delves into the intricate landscape of cardiorenal syndrome (CRS) and highlights the pivotal role of blood volume analysis (BVA) in improving patient care and outcomes. SUMMARY BVA offers a direct and highly accurate quantification of intravascular volume, red blood cell volume, and plasma volume, complete with patient-specific norms. This diagnostic tool enhances the precision of diuretic and red cell therapies, significantly elevating the effectiveness of conventional care. KEY MESSAGES Our objectives encompass a comprehensive understanding of how BVA informs the evaluation and treatment of CRS, including its subtypes, pathophysiology, and clinical significance. We delve into BVA principles, techniques, and measurements, elucidating its diagnostic potential and advantages compared to commonly used surrogate measures. We dissect the clinical relevance of BVA in various CRS scenarios, emphasizing its unique contributions to each subtype. By assessing the tangible impact of BVA on patient outcomes through meticulous analysis of relevant clinical studies, we unveil its potential to enhance health outcomes and optimize resource utilization. Acknowledging the challenges and limitations associated with BVA's clinical implementation, we underscore the importance of multidisciplinary collaboration among cardiologists, nephrologists, and other clinicians. Finally, we identify research gaps and propose future directions for BVA and CRS, contributing to ongoing advancements in this field and patients affected by this complicated clinical syndrome.
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Affiliation(s)
| | | | - Marc A Silver
- University of Arizona-Phoenix, Department of Medicine, Phoenix, Arizona, USA
| | - Javed Butler
- University of Mississippi, Department of Medicine, Jackson, Mississippi, USA
| | - Harvey David Humes
- University of Michigan Health, Division of Nephrology, Internal Medicine, Ann Arbor, Michigan, USA
| | - John Strobeck
- Heart-Lung Center Consultants, New Milford, New Jersey, USA
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Miller WL. Measurement of Blood Volume in Patients with Heart Failure: Clinical Relevance, Surrogates, Historical Background and Contemporary Methodology. Heart Int 2023; 17:36-43. [PMID: 37456346 PMCID: PMC10339432 DOI: 10.17925/hi.2023.17.1.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/22/2023] [Indexed: 07/18/2023] Open
Abstract
The development of clinical congestion resulting from volume overload, either by renal fluid retention or redistribution of blood volume from venous reservoirs, is a recurrent scenario in patients with chronic heart failure (HF). As a result, the treatment of congestion, most commonly by initiating aggressive diuretic therapy, is a front-line issue in the management of patients with HF. However, the association of clinical congestion and volume overload with physical signs and symptoms, as well as other surrogates of volume assessment, has limitations in accuracy and, therefore, reliability to direct appropriate interventions. The ability to quantitate intravascular volume and identify the variability in volume profiles among patients with HF can uniquely inform individualized volume management and aid in risk stratification. This tool is provided by contemporary nuclear medicine-based BVA-100 methodology, which uses the well-established indicator-dilution principle and is a requested topic for discussion in this review.
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Affiliation(s)
- Wayne L Miller
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Molitoris BA, George AG, Murray PT, Meier D, Reilly ES, Barreto E, Sandoval RM, Rizk DV, Shaw AD, Peacock WF. A Novel Fluorescent Clinical Method to Rapidly Quantify Plasma Volume. Cardiorenal Med 2019; 9:168-179. [PMID: 30844821 PMCID: PMC7175413 DOI: 10.1159/000496480] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/28/2018] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES To determine the performance of a rapid fluorescent indicator technique for measuring plasma volume (PV). METHODS This was an open-label, observational evaluation of a two-component intravenous visible fluorescent dye technique to rapidly measure PV in 16 healthy subjects and 16 subjects with chronic kidney disease (8 stage 3 and 8 stage 4 CKD), at 2 clinical research sites. The method consisted of a single intravenous injection of 12 mg of a large 150-kDa carboxy-methyl dextran conjugated to a fluorescent rhodamine-derived dye as the PV marker (PVM), and 35 mg of a small 5-kDa carboxy-methyl dextran conjugated to fluorescein, the renal clearance marker. Dye concentrations were quantified 15 min after the injections for initial PV measurements using the indicator-dilution principle. Additional samples were taken over 8 h to evaluate the stability of the PVM as a determinant of PV. Blood volumes (BV) were calculated based on PV and the subject's hematocrit. Pharmacokinetic parameters were calculated from the plasma concentration data taken over several days using noncompartmental methods (Phoenix WinNonlin®). Linear correlation and Bland-Altman plots were used to compare visible fluorescent injectate-measured PV compared to Nadler's formula for estimating PV. Finally, 8 healthy subjects received 350 mL infusion of a 5% albumin solution in normal saline over 30 min and a repeat PV determination was then carried out. RESULTS PV and BV varied according to weight and body surface area, with PV ranging from 2,115 to 6,234 mL and 28.6 to 41.9 mL/kg when weight adjusted. Both parameters were stable for > 6 h with repeated plasma measurements of the PVM. There was no difference between healthy subjects and CKD subjects. Overall, there was general agreement with Nadler's estimation formula for the mean PV in subjects. A 24-h repeat dose measurement in 8 healthy subjects showed PV variability of 98 ± 121 mL (mean = 3.8%). Additionally, following an intravenous bolus of 350 mL of a 5% albumin solution in normal saline in 8 healthy subjects, the mean (SD) measured increase in PV was 356 (±50.0) mL post-infusion. There were no serious adverse events reported during the study. CONCLUSIONS This minimally invasive fluorescent dye approach safely allowed for rapid, accurate, and reproducible determination of PV, BV, and dynamic monitoring of changes following fluid administration.
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Affiliation(s)
- Bruce A Molitoris
- Indiana University, Indianapolis, Indiana, USA,
- FAST BioMedical, Carmel, Indiana, USA,
| | - Anthony G George
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | | | - Ruben M Sandoval
- Indiana University, Indianapolis, Indiana, USA
- FAST BioMedical, Carmel, Indiana, USA
| | - Dana V Rizk
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
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Abstract
PURPOSE OF REVIEW Protocolized care for early shock resuscitation (PCESR) has been intensely examined over the last decade. The purpose is to review the pathophysiologic basis, historical origin, clinical applications, components and outcome implications of PCESR. RECENT FINDINGS PCESR is a multifaceted systems-based approach that includes early detection of high-risk patients and interventions to rapidly reverse hemodynamic perturbations that result in global or regional tissue hypoxia. It has been applied to perioperative surgery, trauma, cardiology (heart failure and acute myocardial infarction), pulmonary embolus, cardiac arrest, undifferentiated shock, postoperative cardiac surgery and pediatric septic shock. When this approach is used for adult septic shock, in particular, it is associated with a mortality reduction from 46.5 to less than 30% over the last 2 decades. Challenges to these findings are seen when repeated trials contain enrollment, diagnostic and therapeutic methodological differences. SUMMARY PCESR is more than a hemodynamic optimization procedure. It also provides an educational framework for the less experienced and objective recognition of clinical improvement or deterioration. It further minimizes practices' variation and provides objective measures that can be audited, evaluated and amendable to continuous quality improvement. As a result, morbidity and mortality are improved.
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Furuta S, Inouye DS, Hayashi MS, Takanishi DM, Yu M. Blood volume measured by ultrasound and radioisotope dilution in critically ill subjects. J Surg Res 2017; 207:77-84. [DOI: 10.1016/j.jss.2016.08.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/26/2016] [Accepted: 08/24/2016] [Indexed: 02/08/2023]
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Brain-type natriuretic peptide and right ventricular end-diastolic volume index measurements are imprecise estimates of circulating blood volume in critically ill subjects. J Trauma Acute Care Surg 2014; 75:813-8. [PMID: 24158199 DOI: 10.1097/ta.0b013e3182a85f3a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surrogate indicators have often been used to estimate intravascular volume to guide fluid management. Brain-type natriuretic peptide (BNP) has been used as a noninvasive adjunct in the diagnosis of fluid overload and as a marker of response to therapy, especially in individuals with congestive heart failure. Similarly, right ventricular end-diastolic volume index (RVEDVI) measurements represent another parameter used to guide fluid resuscitation. The aim of this study was to evaluate whether BNP and RVEDVI are clinically valuable parameters that can distinguish among hypovolemia, euvolemia, and hypervolemia, as measured by blood volume (BV) analysis in critically ill surgical subjects. METHODS This observational study was part of a prospective, randomized controlled trial. Subjects with pulmonary artery catheters for the treatment of traumatic injuries, severe sepsis/septic shock, cardiovascular collapse, adult respiratory distress syndrome, and postsurgical care were studied. Circulating BV was measured by a radioisotope dilution technique using the BVA-100 Analyzer (Daxor Corporation, New York, NY) within the first 24 hours of acute resuscitation. BV results were reported as percent deviation from the patient's ideal BV based on height and percent deviation from optimum weight. Hypovolemia was defined as less than 0%, euvolemia was defined as 0% to +16%, and hypervolemia was defined as greater than +16% deviation from ideal BV. RVEDVI was measured by continuous cardiac output pulmonary artery catheters (Edwards Lifesciences, Irvine, CA). BNP and RVEDVI measurements obtained with BV analysis were evaluated with Fisher's exact test and regression analysis. RESULTS In 81 subjects, there was no difference in BV status between those with BNP of 500 pg/mL or greater and BNP of less than 500 pg/mL (p = 0.82) or in those with RVEDVI of 140 mL/m or greater and RVEDVI of less than 140 mL/m (p = 0.43). No linear relationship existed between BV and these parameters. CONCLUSION In critically ill surgical patients, BNP and RVEDVI were not associated with intravascular volume status, although they may be useful as indices that reflect increased cardiac preload. LEVEL OF EVIDENCE Diagnostic study, level III.
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Wang H, Shi R, Mahler S, Gaspard J, Gorchynski J, D'Etienne J, Arnold T. Vascular pedicle width on chest radiograph as a measure of volume overload: meta-analysis. West J Emerg Med 2012; 12:426-32. [PMID: 22224132 PMCID: PMC3236159 DOI: 10.5811/westjem.2011.3.2023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Revised: 01/19/2011] [Accepted: 03/28/2011] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Vascular pedicle width (VPW), a measurement obtained from a chest radiograph (CR), is thought to be an indicator of circulating blood volume. To date there are only a handful of studies that demonstrate a correlation between high VPW and volume overload, each utilizing different VPW values and CR techniques. Our objective was to determine a mean VPW measurement from erect and supine CRs and to determine whether VPW correlates with volume overload. METHODS MEDLINE database, Web of Science, and the Cochrane Central Register of Controlled Trials were searched electronically for relevant articles. References from the original and review publications selected electronically were manually searched for additional relevant articles. Two investigators independently reviewed relevant articles for inclusion criteria and data extraction. Mean VPW measurements from both supine and erect CRs and their correlation with volume overload were calculated. RESULTS Data from 8 studies with a total of 363 subjects were included, resulting in mean VPW measurements of 71 mm (95% confidence interval [CI] 64.9-77.3) and 62 mm (95% CI 49.3-75.1) for supine and erect CRs, respectively. The correlation coefficients for volume overload and VPW were 0.81 (95% CI 0.74-0.86) for both CR techniques and 0.81 (95% CI 0.72-0.87) for supine CR and 0.80 (95% CI 0.69-0.87) for erect CR, respectively. CONCLUSION There is a clinical and statistical correlation between VPW and volume overload. VPW may be used to evaluate the volume status of a patient regardless of the CR technique used.
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Affiliation(s)
- Hao Wang
- JPS Health Network, Department of Emergency Medicine, Fort Worth, Texas
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Proskurnin MA, Zhidkova TV, Volkov DS, Sarimollaoglu M, Galanzha EI, Mock D, Nedosekin DA, Zharov VP. In vivo multispectral photoacoustic and photothermal flow cytometry with multicolor dyes: a potential for real-time assessment of circulation, dye-cell interaction, and blood volume. Cytometry A 2011; 79:834-47. [PMID: 21905207 DOI: 10.1002/cyto.a.21127] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 06/29/2011] [Accepted: 07/26/2011] [Indexed: 01/08/2023]
Abstract
Recently, photoacoustic (PA) flow cytometry (PAFC) has been developed for in vivo detection of circulating tumor cells and bacteria targeted by nanoparticles. Here, we propose multispectral PAFC with multiple dyes having distinctive absorption spectra as multicolor PA contrast agents. As a first step of our proof-of-concept, we characterized high-speed PAFC capability to monitor the clearance of three dyes (Indocyanine Green [ICG], Methylene Blue [MB], and Trypan Blue [TB]) in an animal model in vivo and in real time. We observed strong dynamic PA signal fluctuations, which can be associated with interactions of dyes with circulating blood cells and plasma proteins. PAFC demonstrated enumeration of circulating red and white blood cells labeled with ICG and MB, respectively, and detection of rare dead cells uptaking TB directly in bloodstream. The possibility for accurate measurements of various dye concentrations including Crystal Violet and Brilliant Green were verified in vitro using complementary to PAFC photothermal (PT) technique and spectrophotometry under batch and flow conditions. We further analyze the potential of integrated PAFC/PT spectroscopy with multiple dyes for rapid and accurate measurements of circulating blood volume without a priori information on hemoglobin content, which is impossible with existing optical techniques. This is important in many medical conditions including surgery and trauma with extensive blood loss, rapid fluid administration, and transfusion of red blood cells. The potential for developing a robust clinical PAFC prototype that is safe for human, and its applications for studying the liver function are further highlighted.
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A prospective randomized trial using blood volume analysis in addition to pulmonary artery catheter, compared with pulmonary artery catheter alone, to guide shock resuscitation in critically ill surgical patients. Shock 2011; 35:220-8. [PMID: 20926981 DOI: 10.1097/shk.0b013e3181fc9178] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Measurement of blood volume (BV) may guide fluid and red blood cell management in critically ill patients when capillary leak from shock and fluid resuscitation makes assessment of intravascular volume difficult. This is a prospective randomized trial of critically ill surgical patients with septic shock, severe sepsis, severe respiratory failure, and/or cardiovascular collapse. The control group received fluid management based on pulmonary artery catheter parameters and red blood cell transfusions based on hematocrit values. The BV group received fluid and red blood cell transfusions based on BV analyses in addition to pulmonary artery catheter parameters. Blood volume was measured using the radioisotope tracer technique with iodine 131-labeled albumin. This allowed direct measurement of plasma volume and calculation of the red blood cell volume. The control group was blinded to the BV results. There were statistically significantly more times when the control group (compared with the BV group) demonstrated hypervolemia (48% vs. 37%) and red blood cell deficiency (33% vs. 16%). There was a delay in red blood cell transfusions administered to the control group by 1.5 +/- 2 days at which time the abnormality became clinically evident. Blood volume analyses provided additional information to the clinicians resulting in a change in treatment in 44% of the time to patients randomized to the BV group. The mortality rates were significantly different between the two groups (8% for the BV group and 24% in the control group; P = 0.03). Blood volume measurements allowed the physicians to promptly treat physiologic disturbances in both red blood cell volume and plasma volume, resulting in improved survival.
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