Identification of microemboli during haemodialysis using Doppler ultrasound

Non-anticoagulation pediatric continuous renal replacement therapy methods to increase circuit life

INTRODUCTION

Acute kidney injury (AKI) is a clinical condition characterized by an abrupt increase in serum creatinine levels due to functional changes in the kidneys from a newfound insult or injury. For supportive treatment, continuous renal replacement therapy (CRRT) is one of the most widely used modalities due to its precise control of fluid balance over extended periods of time. However, its complications include circuit clotting, the most frequent cause for CRRT interruption. Vascular access and circuit management were found to be major determinants of performance efficiency. Anticoagulation required to prevent clotting has the downside of increasing the risk of bleeding, especially in the setting of overdosage. Hence, a delicate balance needs to be maintained consistently.

METHODS

This study explores the adequacy of non-anticoagulation measures in the prevention of circuit clotting. A comprehensive literature search was conducted using PubMed/Medline and Embase databases to include all relevant studies.

FINDINGS

The most-effective CRRT catheter would be made of nonthrombogenic material, noncuffed and nontunneled with separate lumens for arterial and venous blood. Further, studies show that blood flow during the process is optimized at 200 ml/min, which can be lowered in the pediatric population due to more narrow catheters. Platelet count and hematocrit need to be closely monitored as levels above 450,000 × 10⁶ /L and 0.40, respectively, increase risk of clotting. Predilution is a non-anticoagulation technique to reduce the risk of clotting by returning replacement solution to the blood before it reaches the filter. Also, biocompatible membranes such as polyacrylonitrile or polysulfone activate the coagulation cascade significantly less than the conventional cellulose-based membranes, thereby reducing clotting chances.

DISCUSSIONS

With the advent of such techniques and maneuvers, anticoagulation can be efficiently maintained in patients undergoing CRRT without increasing the risk of bleeding.

Air contamination during medical treatment results in deposits of microemboli in the lungs: An autopsy study

INTRODUCTION

Microbubbles of air may enter into patients during conventional hemodialysis, infusions of fluids, or by injections. The aim of this study was to investigate whether the air that enters the patient during hemodialysis can be detected in the lungs after death, and if so, whether this may be related to tissue damage.

METHODS

The material consisted of lung tissue from five chronic hemodialysis patients who died either during (two) or after hemodialysis (range 10 min from start until 3333 min after the last hemodialysis session); as reference group tissue was taken from seven patients who died due to amyotrophic lateral sclerosis. The lung tissue was investigated by microscopy after autopsy using a fluorescein-marked polyclonal antibody against fibrinogen as a marker for clots preformed before death.

RESULTS

All five hemodialysis patients had microbubbles of air in the lung tissue, whereas two of seven amyotrophic lateral sclerosis patients had such findings (Fisher's test p = 0.0278, relative risk = 3.5, confidence interval: 1.08-11.3). There were more microbubbles of air/10 randomly investigated microscopic fields of tissue in the hemodialysis patients than the amyotrophic lateral sclerosis patients (Student's test, p < 0.05). All hemodialysis patients had a medium graded extent of pulmonary fibrosis that was not found in any of the ALS patients. The microbubbles of air were surrounded by fibrin as a sign of development of clots around the air bubbles while the patients were still alive.

CONCLUSION

Exposure to microbubbles of air during various treatments such as hemodialysis may result in microemboli. Future studies should clarify whether microbubbles of air contribute to tissue scarring. We suggest preventive measures against the exposure to microbubbles of air during especially repeated exposures such as hemodialysis.

Cerebral Gaseous Microemboli are Detectable During Continuous Venovenous Hemodialysis in Critically Ill Patients: An Observational Pilot Study

BACKGROUND

Continuous venovenous hemodialysis (CVVHD) may generate microemboli that cross the pulmonary circulation and reach the brain. The aim of the present study was to quantify (load per time interval) and qualify (gaseous vs. solid) cerebral microemboli (CME), detected as high-intensity transient signals, using transcranial Doppler ultrasound.

MATERIALS AND METHODS

Twenty intensive care unit (ICU group) patients requiring CVVHD were examined. CME were recorded in both middle cerebral arteries for 30 minutes during CVVHD and a CVVHD-free interval. Twenty additional patients, hospitalized for orthopedic surgery, served as a non-ICU control group. Statistical analyses were performed using the Mann-Whitney U test or the Wilcoxon matched-pairs signed-rank test, followed by Bonferroni corrections for multiple comparisons.

RESULTS

In the non-ICU group, 48 (14.5-169.5) (median [range]) gaseous CME were detected. In the ICU group, the 67.5 (14.5-588.5) gaseous CME detected during the CVVHD-free interval increased 5-fold to 344.5 (59-1019) during CVVHD (P<0.001). The number of solid CME was low in all groups (non-ICU group: 2 [0-5.5]; ICU group CVVHD-free interval: 1.5 [0-14.25]; ICU group during CVVHD: 7 [3-27.75]).

CONCLUSIONS

This observational pilot study shows that CVVHD was associated with a higher gaseous but not solid CME burden in critically ill patients. Although the differentiation between gaseous and solid CME remains challenging, our finding may support the hypothesis of microbubble generation in the CVVHD circuit and its transpulmonary translocation toward the intracranial circulation. Importantly, the impact of gaseous and solid CME generated during CVVHD on brain integrity of critically ill patients currently remains unknown and is highly debated.

Observation of microbubbles during standard dialysis treatments

Background

The infusion of microbubbles as a side effect of haemodialysis was repeatedly demonstrated in recent publications, but the knowledge on the source of microbubbles and on microbubble formation is scarce.

Methods

Microbubbles in the range of 10–500 µm were measured by a non-invasive bubble counter based on a pulsed ultrasonic Doppler system in a non-interventional study of a single centre. Totally, 29 measurements were performed in standard treatments covering a broad range of patient and treatment conditions (types of blood access, treatment modes, blood flow rates and arterial pressures).

Results

Several possible sources of microbubbles could be identified such as an arterial luer lock connector at negative pressure and remnant bubbles from insufficient priming, but some sources of microbubbles remain unknown. Microbubbles were found in all treatments, haemodialysis (HD) and online haemodiafiltration. The lowest average microbubble rates (17 ± 16 microbubbles per minute) were observed in patients treated by online haemodiafiltration at medium blood flow rates and moderate arterial pressures and the highest average microbubble rates (117 ± 63 microbubbles per minute) at high blood flow rates (550 mL/min) and low arterial pressures (−210 mmHg). Generally, the microbubble rate correlated to both blood flow rate (correlation coefficient r = 0.45) and negative arterial pressure (r = 0.67).

Conclusions

Microbubbles are a general side effect of HD; origin and pathophysiologic consequences of this phenomenon are not well understood, and deserve further study.

Effectiveness of microbubble removal in an airtrap with a free surface interface

An end stage renal disease patient will undergo haemodialysis (HD) three or four times a week for four to five hours per session. Because of the chronic nature of the treatment, any minor imperfection in the extracorporeal system may become significant over time. Clinical studies have raised concerns relating to small microbubbles entering HD patients. These bubbles lead to further pathophysiological complications with the size of the bubble being a major factor. Microbubbles of different sizes can be generated throughout the extra-corporeal HD circuit. It is important to understand the possibility of these bubbles passing through the air trap or successfully being removed which indicates the performance of the air trap, the only mechanics of removing air bubbles. Chronic exposure to various sizes of microbubbles was analysed in detail for haemodialysis patients. However, smaller microbubbles are shown to be able to pass our modelled air trap. While studies have reported the presence of bubbles before and after the air trap, because these bubbles are only counted and not tracked, the performance of the air trap for removing different bubble sizes is not understood. Here, the performance of the air trap in filtering bubbles and the possibility of different bubble sizes passing through the air trap with the presence of the free surface interface have been evaluated. The modelled air trap is shown to be ineffective for filtering small micro bubbles.

Pulsatility Produced by the Hemodialysis Roller Pump as Measured by Doppler Ultrasound

Microbubbles have previously been detected in the hemodialysis extracorporeal circuit and can enter the blood vessel leading to potential complications. A potential source of these microbubbles is highly pulsatile flow resulting in cavitation. This study quantified the pulsatility produced by the roller pump throughout the extracorporeal circuit. A Sonosite S-series ultrasound probe (FUJIFILM Sonosite Inc., Tokyo, Japan) was used on a single patient during normal hemodialysis treatment. The Doppler waveform showed highly pulsatile flow throughout the circuit with the greatest pulse occurring after the pump itself. The velocity pulse after the pump ranged from 57.6 ± 1.74 cm/s to -72 ± 4.13 cm/s. Flow reversal occurred when contact between the forward roller and tubing ended. The amplitude of the pulse was reduced from 129.6 cm/s to 16.25 cm/s and 6.87 cm/s following the dialyzer and venous air trap. This resulted in almost nonpulsatile, continuous flow returning to the patient through the venous needle. These results indicate that the roller pump may be a source of microbubble formation from cavitation due to the highly pulsatile blood flow. The venous air trap was identified as the most effective mechanism in reducing the pulsatility. The inclusion of multiple rollers is also recommended to offer an effective solution in dampening the pulse produced by the pump.

A high blood level in the air trap reduces microemboli during hemodialysis

Previous studies have demonstrated the presence of air microemboli in the dialysis circuit and in the venous circulation of the patients during hemodialysis. In vitro studies indicate that a high blood level in the venous air trap reduces the extent of microbubble formation. The purpose of this study was to examine whether air microbubbles can be detected in the patient's access and if so, whether the degree of microbubble formation can be altered by changing the blood level in the venous air trap. This was a randomized, double-blinded, interventional study of 20 chronic hemodialysis patients. The patients were assigned to hemodialysis with either an elevated or a low blood level in the air trap. The investigator and the patient were blinded to the settings. The numbers of microbubbles were measured at the site of the arteriovenous (AV) access for 2 min with the aid of an ultrasonic Doppler device. The blood level in the air trap was then altered to the opposite setting and a new measurement was carried out after an equilibration period of 30 min. Median (range) for the number of microbubbles measured with the high air trap level and the low air trap level in AV access was 2.5 (0-80) compared with 17.5 (0-77), respectively (P = 0.044). The degree of microbubble formation in hemodialysis patients with AV access was reduced significantly if the blood level in the air trap was kept high. The exposure of potentially harmful air microbubbles was thereby significantly reduced. This measure can be performed with no additional healthcare cost.

Microemboli, developed during haemodialysis, pass the lung barrier and may cause ischaemic lesions in organs such as the brain

BACKGROUND

Chronic haemodialysis (HD) may relieve some medical problems of terminal uraemia, but the life expectancy of patients is still significantly shortened, and there is a greatly increased morbidity. This includes pulmonary morbidity and chronic central nervous system (CNS) abnormalities. Previous studies have shown that a considerable amount of air microbubbles emanate within the blood lines of the dialysis device and pass the air detector without sounding an alarm. The aim of this study was to investigate whether microemboli can pass to the patient and whether they could be detected in the carotid artery.

METHODS

A total of 54 patients on chronic HD (16 with central dialysis catheter) were investigated with an ultrasound detector (Hatteland, Røyken, Norway) for the presence of microemboli at the arteriovenous (AV) fistula/graft and at the common carotid artery before and during HD. Measurements were taken for 2 and 5 min, respectively. Non-parametric paired statistics were used (Wilcoxon).

RESULTS

The median number (range) and mean +/- SD of microembolic signals detected at the AV access site before commencing dialysis and during HD were 0 (0-3) and 0.2+/- 0.5 versus 4 (0-85) and 13.5 +/- 20 (P = 0.000); at the carotid artery, 1 (0-14) and 1.7 +/- 2.9 versus 2 (0-36) and 3.5 +/- 5.8 (P = 0.008).

CONCLUSIONS

The infused and returning fluid from HD devices contains air microbubbles that enter the patient without triggering any alarms. These small emboli pass the lung and may cause ischaemic lesions in organs supported by the arterial circuit, such as the brain.

Hemodialysis dialyzers contribute to contamination of air microemboli that bypass the alarm system in the air trap

BACKGROUND

Previous studies have shown that micrometer-sized air bubbles are introduced into the patient during hemodialysis. The aim of this study was to investigate, in vitro, the influence of dialysis filters on the generation of air bubbles.

METHODS

Three different kind of dialyzers were tested: one high-flux FX80 dry filter (Fresenius Medical Care AG&Co. KGaA, Bad Homburg, Germany), one low-flux F8HPS dry filter (Fresenius Medical Care AG&Co. KGaA, Bad Homburg, Germany) and a wet-stored APS-18u filter (Asahi Kasei Medical, Tokyo, Japan). The F8HPS was tested with pump flow ranging between 100 to 400 ml/min. The three filters were compared using a constant pump flow of 300 ml/min. Measurements were performed using an ultrasound Doppler instrument.

RESULTS

In 90% of the series, bubbles were measured after the outlet line of the air trap without triggering an alarm. There were significantly more bubbles downstream than upstream of the filters F8HPS and FX80, while there was a significant reduction using the APS-18u. There was no reduction in the number of bubbles after passage through the air trap versus before the air trap (after the dialyzer). Increased priming volume reduced the extent of bubbles in the system.

CONCLUSIONS

Data indicate that the air trap does not prevent air microemboli from entering the venous outlet part of the dialysis tubing (entry to the patient). More extended priming of the dialysis circuit may reduce the extent of microemboli that originate from dialysis filters. A wet filter may be favorable instead of dry-steam sterilized filters.

Acoustical bubble trapper applied to hemodialysis

Gaseous microemboli can arise in extracorporeal lines and devices such as dialysis machines. They are associated with severe pulmonary side effects in patients undergoing chronic hemodialysis sessions. The goal of this study was to develop a gaseous emboli trapper using ultrasound waves to remove any air bubble from the tubing system before they reach the patient. A homemade bubble trapper, developed in the laboratory, consists of a Perspex block containing a main channel connected to the tubing of a hemodialysis machine and a second subchannel positioned perpendicularly to the main one, used to trap the air microemboli. The microemboli flowing in the main channel were insonified through an acoustic window with an ultrasound wave, at a frequency of 500 kHz and with a maximal acoustic pressure of 500 kPa, generated by a single-element transducer positioned 3 cm away from the main flow. The radiation force induced by the ultrasound beam acts directly on the flowing air emboli, by pushing them into the subchannel. Two Doppler probes operating both at 2 MHz, connected to a DWL Doppler machine were placed before and after the bubble trapper to count sequentially the number of embolic events. The flow of the machine was varied between 200 mL/min and 500 mL/min. Depending on the flow velocity, the number of microembolic signals (MES) detected by the Doppler probes before and after the trapping system was identical and ranged from 5 to 150 MES/min in absence of the ultrasound irradiation. When the air bubble trapper was activated, a reduction of the number of MES, up to 70%, was achieved. Doppler recordings suggest that the circulating bubbles were either fragmented into smaller bubble fragments or directly got pushed into the second subchannel where they were collected. This simple approach using an ultrasound-based trapping system was shown to operate adequately with the current settings and can be used to filter air microemboli.

Development of Air Micro Bubbles in the Venous Outlet Line: An In Vitro Analysis of Various Air Traps Used for Hemodialysis

Venous air traps were tested in vitro with respect to presence of micro bubbles. Three types of venous air traps were measured (Bioline, Bioline GmbH, Luckenwalde, Germany; Gambro, Gambro AB, Lund, Sweden; Fresenius M.C., Fresenius Medical Care AG & Co. KGaA, Bad Homburg, Germany). Measurements (n = 10) were taken for each air trap, fluid flow (50-600 mL/min), and fluid level (high/low). A 1.5-MHz ultrasound probe was used with an analysis device. The probe was mounted on the outlet line downstream of the venous air trap. A semisynthetic fluid was used to resemble blood viscosity. Occurrences of micro bubbles, without inducing an alarm of the dialysis device, were detected in almost all measurements. The amount of bubbles increased with increasing flow. There were more bubbles with low fluid level compared with high level. The Bioline tubing released the least bubbles in high fluid level. At low level, the Gambro tubing showed the least bubbles at flows 50-400 mL/min, and the Fresenius M.C. tubing showed the least bubbles at flows 400-600 mL/min. High fluid level in the air trap reduced generation of micro bubbles compared to low level, as did lower fluid flow versus high flow. The design of the air trap was also of importance.

Air Bubbles Pass the Security System of the Dialysis Device Without Alarming

During hemodialysis microembolic findings have been noted after the venous chamber (subclavian vein). The aim of this study was to evaluate if air could pass the venous chamber and, if so, if it passes the safety-system detector for air-infusion without triggering an alarm. Various in vitro dialysis settings were performed using regular dialysis devices. A dextran fluid was used instead of blood to avoid the risk of development of emboli. Optical visualization as well as recirculation and collection of eventual air into an intermediate bag were investigated. In addition, a specifically designed ultrasound monitor was placed after the venous air trap to measure the presence of eventual microbubbles. Speed of dialysis fluid was changed, as was the level of the fluid in the air trap. Thereby a fluid level was considered "high" if it was close to the top of the air trap and "low" if it was around the mid part of the air trap. By optical vision microbubbles were seen at the bottom of the air trap and could pass the air trap towards the venous line without alarming. During recirculation several mL of air were collected in an intermediate bag after the venous line. Ultrasound monitoring exhibited the presence of microbubbles of the size of approximately 5 microm upwards passing to the venous line in all runs performed. Amount of bubbles differed between devices and in general an increased fluid speed correlated significantly with the increased counts of microbubbles/min. No alarming of the detector occurred. A more concentrated fluid allowed higher counts/min when flow was increased to 600 mL/min. Data revealed that air passes the safety-sensor in the air trap without alarming. The presence of air increased in general with fluid speed and a lower fluid level in the air trap. Differences were present between devices. If this affects the patients has to be elucidated.

The Sensor in the Venous Chamber Does Not Prevent Passage of Air Bubbles During Hemodialysis

We previously showed, in vitro, that micro bubbles pass the air trap without inducing an alarm. The aim was to investigate if micro bubbles bypass the detector during hemodialysis (HD). During HD (40 patients, 47 HD sessions, 231 measurements), an ultrasound detector was fixed just after the venous air trap. Micro bubble size was measured in the range from 5 microm up to >42.5 microm. Blood flow was at a mean 346 mL/min (SD +/- 57). The mean of all micro bubbles per minute, without inducing an alarm, was at start 128 (range 0-769). Measurements revealed the presence of micro bubbles in all of the series and in 90% of the measurements. There was no difference between start and end of the same dialyses. There was a correlation between blood flow and extent of micro bubbles for the smaller sizes and the sum of all bubbles (r > or = 0.29, P < or = 0.026). Micro bubbles passed the air trap without alarming. Most bubbles were approximately 5 microm.

Microbubbles

Gas embolism is a known complication of various invasive procedures, and its management is well established. The consequence of gas microemboli, microbubbles, is underrecognized and usually overlooked in daily practice. We present the current data regarding the pathophysiology of microemboli and their clinical consequences. Microbubbles originate mainly in extracorporeal lines and devices, such as cardiopulmonary bypass and dialysis machines, but may be endogenous in cases of decompression sickness or mechanical heart valves. Circulating in the blood stream, microbubbles lodge in the capillary bed of various organs, mainly the lungs. The microbubble obstructs blood flow in the capillary, thus causing tissue ischemia, followed by inflammatory response and complement activation. Aggregation of platelets and clot formation occurs as well, leading to further obstruction of microcirculation and tissue damage. In this review, we present evidence of the biological and clinical detrimental effects of microbubbles as demonstrated by studies in animal models and humans, and discuss management of the microbubble problem with regard to detection, prevention, and treatment.

Detection of microemboli in the subclavian vein of patients undergoing haemodialysis and haemodiafiltration using pulsed Doppler ultrasound

BACKGROUND

The pathophysiology leading to pulmonary side effects during haemodialysis and haemodiafiltration is not yet fully understood. Chronic microembolization, which can be demonstrated by pulsed Doppler ultrasound, may be one cause.

METHODS

The study cohort consisted of 24 long-term dialysis patients undergoing haemodialysis (n=21) and online-haemodiafiltration (n=3), respectively. The subclavian vein downstream to the venous access was investigated during different phases of the procedure using a 2-MHz pulsed ultrasound device.

RESULTS

In all periods investigated (connection, dialysis, disconnection), numerous microembolic signals (MES) were found in the subclavian vein. The numbers of MES detected during haemodiafiltration (314-709 MES per 10 min) were higher than during haemodialysis (0-81 MES per 10 min).

CONCLUSIONS

The composition (gaseous or solid) and origin (pump, tubing system or shunt) of the microemboli detected remains unclear. Chronic microembolization may be one cause of pulmonary complications of haemodialysis and haemodiafiltration. The detection method described in this article will help us to better understand this process and to determine what role microemboli might play in pulmonary and central nervous system disorders. It may also help to optimize the devices and techniques used.

Associations of plasma endothelin concentration with carotid atherosclerosis and asymptomatic cerebrovascular lesions in patients with essential hypertension

We studied the association of endothelin (ET)-1 with carotid atherosclerosis and asymptomatic cerebrovascular lesions in patients with essential hypertension. Neurologically normal patients with essential hypertension (n=293; 138 male, 155 female; mean age, 65 years) and age-matched control subjects (n=242) were studied with B-mode ultrasonography of the common and internal carotid arteries and magnetic resonance imaging of the brain. Plasma ET-1 was measured by enzyme immunoassay. Hypertensive patients were divided into groups with carotid plaques and low ET-1 concentrations (< 0.75 pg/ml; PL group); carotid plaques and mid-range ET-1 (0.75 to 1.55 pg/ml; PM group); carotid plaques and high ET-1 (> or = 1.55 pg/ml; PH group); no plaques and low ET-1 (NPL); no plaques and mid-range ET-1 (NPM); and no plaques and high ET-1 (NPH). Overall, ET-1 concentrations were significantly higher in patients than in control subjects. Carotid plaque prevalence was significantly related to ET-1 in hypertensive patients. ET-1 showed a significant positive relationship with the number of asymptomatic lacunar infarcts of the brain in hypertensive patients with carotid plaques (rho=0.48, p<0.001). No significant relationship was seen between ET-1 and periventricular hyperintensity scores in patients with plaques. ET-1 did not show a relationship to either brain lesion type in patients without carotid plaques. Thus, ET-1 may foster asymptomatic lacunar cerebral infarcts by promoting carotid atherosclerosis in patients with essential hypertension.