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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.

Huber W, Fuchs S, Minning A, Küchle C, Braun M, Beitz A, Schultheiss C, Mair S, Phillip V, Schmid S, Schmid RM, Lahmer T - PLoS ONE (2016)

Bottom Line: 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.TPTD is feasible during SLED. "Acute" connection does not substantially impair haemodynamics.

View Article: PubMed Central - PubMed

Affiliation: II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany.

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.

No MeSH data available.


Related in: MedlinePlus

Potential impact of renal replacement therapy (RRT) on transpulmonary thermodilution (TPTD) with potential impact of catheter positions and blood flow.
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Related In: Results  -  Collection

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pone.0153430.g001: Potential impact of renal replacement therapy (RRT) on transpulmonary thermodilution (TPTD) with potential impact of catheter positions and blood flow.

Mentions: This might be related to concerns on the applicability of indicator dilution techniques including TPTD during RRT. From a theoretical viewpoint several potential confounders of thermodilution have to be considered (Fig 1) including loss of indicator in the extracorporeal circuit, interference of temperature changes induced by the extracorporeal circuit and changes in blood pump flow. Furthermore, positioning of the CVC and dialysis catheter in the same position might impair TPTD (both catheters in jugular veins or both catheters in the femoral veins). Some of these interactions are difficult to differentiate from true side effects of RRT including a decrease in preload, cardiac output and arterial pressure as well as an increase in heart rate (HR) and changes in systemic vascular resistance index (SVRI).


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.

Huber W, Fuchs S, Minning A, Küchle C, Braun M, Beitz A, Schultheiss C, Mair S, Phillip V, Schmid S, Schmid RM, Lahmer T - PLoS ONE (2016)

Potential impact of renal replacement therapy (RRT) on transpulmonary thermodilution (TPTD) with potential impact of catheter positions and blood flow.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4835077&req=5

pone.0153430.g001: Potential impact of renal replacement therapy (RRT) on transpulmonary thermodilution (TPTD) with potential impact of catheter positions and blood flow.
Mentions: This might be related to concerns on the applicability of indicator dilution techniques including TPTD during RRT. From a theoretical viewpoint several potential confounders of thermodilution have to be considered (Fig 1) including loss of indicator in the extracorporeal circuit, interference of temperature changes induced by the extracorporeal circuit and changes in blood pump flow. Furthermore, positioning of the CVC and dialysis catheter in the same position might impair TPTD (both catheters in jugular veins or both catheters in the femoral veins). Some of these interactions are difficult to differentiate from true side effects of RRT including a decrease in preload, cardiac output and arterial pressure as well as an increase in heart rate (HR) and changes in systemic vascular resistance index (SVRI).

Bottom Line: 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.TPTD is feasible during SLED. "Acute" connection does not substantially impair haemodynamics.

View Article: PubMed Central - PubMed

Affiliation: II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar; Technische Universität, München, München, Germany.

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.

No MeSH data available.


Related in: MedlinePlus