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Ngoh CLY, Teng HL, Chua YT, Leo CCH, Wong WK. Comparison between lung ultrasonography and current methods for volume assessment in Asian chronic hemodialysis patients. Hemodial Int 2020; 24:516-527. [PMID: 32809269 DOI: 10.1111/hdi.12871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 07/26/2020] [Accepted: 07/27/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Volume assessment in end-stage kidney disease patients on hemodialysis (HD) remains inadequate by existing methods: clinical examination, bioimpedance spectroscopy, measurement of inferior vena cava diameter by ultrasound (IVCD), and plasma B-type natriuretic peptide (NT-pro BNP). This study aims to compare the performance of lung ultrasound against existing methods for volume assessment in a HD cohort. METHODS Two nephrologists independently performed 28-point lung ultrasound immediately before and after midweek HD in 50 patients. Lung congestion was classified into mild, moderate, and severe categories based on lung ultrasound findings. Clinical examination for crepitations and oedema, change in hydration status (∆HS) measured by bioimpedance spectroscopy, NT-pro BNP, IVCD during inspiration (IVCDimin), expiration (IVCDimax), and inferior vena cava collapsibility index were also assessed before and after midweek HD. FINDINGS In all, 61% of patients with normohydration status by bioimpedance spectroscopy had moderate or severe lung congestion on lung ultrasound. There were significant correlations between predialysis lung ultrasound, and NT-pro BNP (r = 0.432, P = 0.004), ∆HS (r = 0.447, P < 0.001), and IVCD parameters (P < 0.05). Some correlations weakened postdialysis (∆HS [r = 0.322, P = 0.01] and IVCDimax [r = 0.307, P = 0.03]), whereas NT-pro BNP and ∆HS paradoxically increased in 28% and 30% of the cohort, respectively. On receiver operator curve analysis, most methods of volume assessment had limited discriminatory power to detect mild lung congestion. DISCUSSION Lung ultrasound demonstrates some comparability with existing volume assessment methods in Asian dialysis patients. However, it appears more effective at detecting subclinical pulmonary congestion, and tracking fluid changes real-time compared to bioimpedance spectroscopy and NT-pro BNP.
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Affiliation(s)
- Clara L Y Ngoh
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hazel L Teng
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore, Singapore
| | - Yan T Chua
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore, Singapore
| | - Christopher C H Leo
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Weng K Wong
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Transpulmonary thermodilution before and during veno-venous extra-corporeal membrane oxygenation ECMO: an observational study on a potential loss of indicator into the extra-corporeal circuit. J Clin Monit Comput 2019; 34:923-936. [DOI: 10.1007/s10877-019-00398-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 10/07/2019] [Indexed: 01/19/2023]
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Huber W, Fuchs S, Minning A, Küchle C, Braun M, Beitz A, Schultheiss C, Mair S, Phillip V, Schmid S, Schmid RM, Lahmer T. Transpulmonary thermodilution (TPTD) before, during and after Sustained Low Efficiency Dialysis (SLED). A Prospective Study on Feasibility of TPTD and Prediction of Successful Fluid Removal. PLoS One 2016; 11:e0153430. [PMID: 27088612 PMCID: PMC4835077 DOI: 10.1371/journal.pone.0153430] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 03/29/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is common in critically ill patients. AKI requires renal replacement therapy (RRT) in up to 10% of patients. Particularly during connection and fluid removal, RRT frequently impairs haemodyamics which impedes recovery from AKI. Therefore, "acute" connection with prefilled tubing and prolonged periods of RRT including sustained low efficiency dialysis (SLED) has been suggested. Furthermore, advanced haemodynamic monitoring using trans-pulmonary thermodilution (TPTD) and pulse contour analysis (PCA) might help to define appropriate fluid removal goals. OBJECTIVES, METHODS Since data on TPTD to guide RRT are scarce, we investigated the capabilities of TPTD- and PCA-derived parameters to predict feasibility of fluid removal in 51 SLED-sessions (Genius; Fresenius, Germany; blood-flow 150 mL/min) in 32 patients with PiCCO-monitoring (Pulsion Medical Systems, Germany). Furthermore, we sought to validate the reliability of TPTD during RRT and investigated the impact of "acute" connection and of disconnection with re-transfusion on haemodynamics. TPTDs were performed immediately before and after connection as well as disconnection. RESULTS Comparison of cardiac index derived from TPTD (CItd) and PCA (CIpc) before, during and after RRT did not give hints for confounding of TPTD by ongoing RRT. Connection to RRT did not result in relevant changes in haemodynamic parameters including CItd. However, disconnection with re-transfusion of the tubing volume resulted in significant increases in CItd, CIpc, CVP, global end-diastolic volume index GEDVI and cardiac power index CPI. Feasibility of the pre-defined ultrafiltration goal without increasing catecholamines by >10% (primary endpoint) was significantly predicted by baseline CPI (ROC-AUC 0.712; p = 0.010) and CItd (ROC-AUC 0.662; p = 0.049). CONCLUSIONS TPTD is feasible during SLED. "Acute" connection does not substantially impair haemodynamics. Disconnection with re-transfusion increases preload, CI and CPI. The extent of these changes might be used as a "post-RRT volume change" to guide fluid removal during subsequent RRTs. CPI is the most useful marker to guide fluid removal by SLED.
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Affiliation(s)
- Wolfgang Huber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
- * E-mail:
| | - Stephan Fuchs
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Andreas Minning
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Claudius Küchle
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Marlena Braun
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Analena Beitz
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Caroline Schultheiss
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Sebastian Mair
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Veit Phillip
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Sebastian Schmid
- Klinik für Anaesthesiologie, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Roland M. Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
| | - Tobias Lahmer
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany
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Elsayed ME, Stack AG. What are the Consequences of Volume Expansion in Chronic Dialysis Patients? Semin Dial 2015; 28:235-9. [DOI: 10.1111/sdi.12351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Mohamed E. Elsayed
- Departments of Nephrology and Internal Medicine; University Hospital Limerick; Limerick Ireland
- Graduate Entry Medical School; University of Limerick; Limerick Ireland
| | - Austin G. Stack
- Departments of Nephrology and Internal Medicine; University Hospital Limerick; Limerick Ireland
- Graduate Entry Medical School; University of Limerick; Limerick Ireland
- Health Research Institute; University of Limerick; Limerick Ireland
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Compton F, Vogel M, Zidek W, van der Giet M, Westhoff T. Changes in volumetric hemodynamic parameters induced by fluid removal on hemodialysis in critically ill patients. Ther Apher Dial 2014; 19:23-9. [PMID: 25196396 DOI: 10.1111/1744-9987.12193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Management of volume status is difficult in critically ill patients with renal failure. Volumetric hemodynamic indices are increasingly being used to guide fluid therapy in the intensive care unit (ICU), but are not established to monitor hemodialysis-induced fluid removal in critically ill patients. Using volumetric hemodynamic monitoring, changes in extravascular lung water index (EVLWI) and intrathoracic blood volume index (ITBVI) were measured immediately before and after hemodialysis sessions in 35 ICU patients. Additional hemodynamic and oxygenation related parameters were recorded at the same time, and online relative blood volume (RBV) monitoring was performed during hemodialysis. EVLWI decreased significantly with fluid removal (median 10.0 vs. 9.6 mL/kg, P = 0.001), whereas ITBVI remained stable (median 1012 vs. 1029 mL/m(2) , P = 0.402). Significant changes were also observed in stroke volume variation (median 12.0 vs. 13.0 %, P = 0.012), cardiac index (median 4.2 vs. 3.5 mL/min/m(2) , P = 0.003), mean arterial pressure (median 77 vs. 85.5 mmHg, P = 0.006), norepinephrine dose (median 0.092 vs. 0.114 μg/kg per min, P = 0.043), and hemoglobin values (median 9.5 vs. 10.4 gm/dL, P = 0.036). RBV decreased by 7.8% (median); there was no correlation with either the volumetric measurements or the other hemodynamic parameters recorded. EVLWI reduction with dialysis reflects the removal of excess body fluid, whereas preservation of cardiac preload is indicated by ITBVI stability. Volumetric hemodynamic measurements provide additional information concerning fluid status and are thus potentially useful to guide fluid removal on hemodialysis in critically ill patients.
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Affiliation(s)
- Friederike Compton
- Department of Nephrology, Charité University Medicine Berlin, Berlin, Germany
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De laet I, Deeren D, Schoonheydt K, Van Regenmortel N, Dits H, Malbrain MLNG. Renal replacement therapy with net fluid removal lowers intra-abdominal pressure and volumetric indices in critically ill patients. Ann Intensive Care 2012; 2 Suppl 1:S20. [PMID: 23282287 PMCID: PMC3527155 DOI: 10.1186/2110-5820-2-s1-s20] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Little is known about the effects of renal replacement therapy (RRT) with fluid removal on intra-abdominal pressure (IAP). The global end-diastolic volume index (GEDVI) and extravascular lung water index (EVLWI) can easily be measured bedside by transpulmonary thermodilution (TPTD). The aim of this study is to evaluate the changes in IAP, GEDVI and EVLWI in critically ill patients receiving slow extended daily dialysis (SLEDD) or continuous venovenous haemofiltration (CVVH) with the intention of net fluid removal. METHODS We performed a retrospective cohort study in ICU patients who were treated with SLEDD or CVVH and in whom IAP was also measured, and RRT sessions were excluded when the dose of vasoactive medication needed to be changed between the pre- and post-dialysis TPTD measurements and when net fluid loss did not exceed 500 ml. The TPTD measurements were performed within 2 h before and after SLEDD; in case of CVVH, before and after an interval of 12 h. RESULTS We studied 25 consecutive dialysis sessions in nine patients with acute renal failure and cardiogenic or non-cardiogenic pulmonary oedema. The GEDVI and EVLWI values before dialysis were 877 ml/m² and 14 ml/kg, respectively. Average net ultrafiltration per session was 3.6 l, with a net fluid loss 1.9 l. The GEDVI decreased significantly during dialysis, but not more than 47.8 ml/m² (p = 0.008), as also did the EVLWI with 1 ml/kg (p = 0.03). The IAP decreased significantly from 12 to 10.5 mmHg (p < 0.0001). CONCLUSIONS Net fluid removal by SLEDD or CVVH in the range observed in this study decreased IAP, GEDVI and EVLWI in critically ill patients although EVLWI reduction was modest.
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Affiliation(s)
- Inneke De laet
- Department of Intensive Care, Ziekenhuisnetwerk Antwerpen (ZNA) Stuivenberg, Lange Beeldekensstraat 267, Antwerp, B-2060, Belgium
| | - Dries Deeren
- Department of Intensive Care, Ziekenhuisnetwerk Antwerpen (ZNA) Stuivenberg, Lange Beeldekensstraat 267, Antwerp, B-2060, Belgium
| | - Karen Schoonheydt
- Department of Intensive Care, Ziekenhuisnetwerk Antwerpen (ZNA) Stuivenberg, Lange Beeldekensstraat 267, Antwerp, B-2060, Belgium
| | - Niels Van Regenmortel
- Department of Intensive Care, Ziekenhuisnetwerk Antwerpen (ZNA) Stuivenberg, Lange Beeldekensstraat 267, Antwerp, B-2060, Belgium
| | - Hilde Dits
- Department of Intensive Care, Ziekenhuisnetwerk Antwerpen (ZNA) Stuivenberg, Lange Beeldekensstraat 267, Antwerp, B-2060, Belgium
| | - Manu LNG Malbrain
- Department of Intensive Care, Ziekenhuisnetwerk Antwerpen (ZNA) Stuivenberg, Lange Beeldekensstraat 267, Antwerp, B-2060, Belgium
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Vukelic V, Peixoto AJ. Are levels of brain natriuretic peptides useful to determine volume status in dialysis patients? Semin Dial 2011; 24:400-2. [DOI: 10.1111/j.1525-139x.2011.00936.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Aboy M, Crespo C, Austin D. An enhanced automatic algorithm for estimation of respiratory variations in arterial pulse pressure during regions of abrupt hemodynamic changes. IEEE Trans Biomed Eng 2009; 56:2537-45. [PMID: 19535315 DOI: 10.1109/tbme.2009.2024761] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We describe an improved automatic algorithm to estimate the pulse-pressure-variation (PPV) index from arterial blood pressure (ABP) signals. This enhanced algorithm enables for PPV estimation during periods of abrupt hemodynamic changes. Numerous studies have shown PPV to be one of most specific and sensitive predictors of fluid responsiveness in mechanically ventilated patients. The algorithm uses a beat detection algorithm to perform beat segmentation, kernel smoothers for envelope detection, and a suboptimal Kalman filter for PPV estimation and artifact removal. In this paper, we provide a detailed description of the algorithm and assess its performance on over 40 h of ABP signals obtained from 18 mechanically ventilated crossbred Yorkshire swine. The subjects underwent grade V liver injury after splenectomy, while receiving mechanical ventilation, and general anesthesia with isoflurane. All subjects in the database underwent a period of abrupt hemodynamic change after an induced grade V liver injury involving severe blood loss resulting in hemorrhagic shock, followed by fluid resuscitation with either 0.9% normal saline or lactated ringers solutions. Trained experts manually calculated PPV at five time instances during the period of abrupt hemodynamic changes. We report validation results comparing the proposed algorithm against a commercial system (pulse contour cardiac output, PICCO) with continuous PPV monitoring capabilities. Both systems were assessed during periods of abrupt hemodynamic changes against the "gold-standard" PPV, calculated and manually annotated by experts. Our results indicate that the proposed algorithm performs considerably better than the PICCO system during regions of abrupt hemodynamic changes.
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Affiliation(s)
- Mateo Aboy
- Electrical Engineering Department, Oregon Institute of Technology (OIT), Portland, OR 97006, USA.
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Palmer BF, Henrich WL. Recent advances in the prevention and management of intradialytic hypotension. J Am Soc Nephrol 2008; 19:8-11. [PMID: 18178796 DOI: 10.1681/asn.2007091006] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Intradialytic hypotension continues to play a significant role in the morbidity and in some cases the mortality associated with maintenance hemodialysis. Greater precision in the determination of dry weight using bioimpedance technology and biofeedback systems designed to prevent rapid fluctuations in blood volume have recently been shown to decrease the frequency of this complication. Pharmacologic strategies designed to maintain peripheral vascular resistance in patients with insufficient release of endogenous vasoconstrictors continue to be explored. The sudden development of intradialytic hypotension may respond to specific antagonists to hypotensive mediators.
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Affiliation(s)
- Biff F Palmer
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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Peixoto AJ. Guest Editor: Rajiv Agarwal: Can “Diagnostic Markers” Predict Blood Pressure Response in Hypertensive Dialysis Patients? Semin Dial 2007; 20:411-5. [PMID: 17897247 DOI: 10.1111/j.1525-139x.2007.00315.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Aldo J Peixoto
- Department of Medicine, Division of Nephrology, Yale University School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Connecticut, USA.
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Compton F, Hoffmann C, Zidek W, Schmidt S, Schaefer JH. Volumetric hemodynamic parameters to guide fluid removal on hemodialysis in the intensive care unit. Hemodial Int 2007; 11:231-7. [PMID: 17403176 DOI: 10.1111/j.1542-4758.2007.00174.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Estimation of removable excess body fluid is difficult in critically ill patients with renal failure. Volumetric hemodynamic parameters are increasingly being used to guide fluid therapy in the intensive care unit, but their suitability to monitor fluid removal with hemodialysis in critically ill patients is not known. Changes in the extravascular lung water index (EVLWI) and intrathoracic blood volume index (ITBVI) measured with transpulmonary thermodilution immediately before and after hemodialysis were analyzed from 39 hemodialysis sessions of 9 patients consecutively treated in the medical intensive care unit of a German University Hospital. Additional hemodynamic, ventilation, and oxygenation-related parameters were recorded at the same time. Online relative blood volume (RBV) monitoring was performed in 29 sessions. Comparisons of pre and postdialysis values showed a significant reduction of the EVLWI with fluid removal (p=0.009), with only a slight nonsignificant decrease in the ITBVI. The cardiac index (CI) also decreased significantly (p=0.010), whereas blood pressure remained stable. Oxygenation improved significantly (p=0.005), and the hematocrit increased significantly with dialysis (p=0.039). There was no correlation between hematocrit changes and RBV measurements. Significant correlations existed between ITBVI and CI changes (p<0.001), but not to EVLWI reduction. The removal of excess body fluid on hemodialysis is reflected by the EVLWI reduction, whereas the preservation of cardiac preload is shown by ITBVI stability. Volumetric hemodynamic parameters could be useful to guide fluid removal with hemodialysis in the intensive care unit.
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Affiliation(s)
- Friederike Compton
- Charité University Medicine Berlin, Campus Benjamin Franklin, Nephrology and Endocrinology, Berlin, Germany.
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