Limits...
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

Flow-chart of potential comparisons before, during and after renal replacement therapy (RRT).Solid lines are used for comparisons aimed at potential real haemodynamic effects of RRT. Dashed lines are given for comparisons aimed at validation of transpulmonary thermodilution (TPTD) technique. MAP: mean arterial pressure. HR: heart rate. PCA: pulse contour analysis. GEDVI: global end-diastolic volume index. EVLWI: extra-vascular lung water index. CI: cardiac index.
© Copyright Policy
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4835077&req=5

pone.0153430.g002: Flow-chart of potential comparisons before, during and after renal replacement therapy (RRT).Solid lines are used for comparisons aimed at potential real haemodynamic effects of RRT. Dashed lines are given for comparisons aimed at validation of transpulmonary thermodilution (TPTD) technique. MAP: mean arterial pressure. HR: heart rate. PCA: pulse contour analysis. GEDVI: global end-diastolic volume index. EVLWI: extra-vascular lung water index. CI: cardiac index.

Mentions: To investigate potential confounding and impact of the RRT itself, haemodynamic measurements can be analyzed at a minimum of 6 different times (Table 1; Fig 2): before (T1) and after connection to RRT with (T2on) and without (T2off) blood flow induced by the blood pump as well as before disconnection with (T3on) and without (T3off) blood pump, and finally after disconnection (T4).


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)

Flow-chart of potential comparisons before, during and after renal replacement therapy (RRT).Solid lines are used for comparisons aimed at potential real haemodynamic effects of RRT. Dashed lines are given for comparisons aimed at validation of transpulmonary thermodilution (TPTD) technique. MAP: mean arterial pressure. HR: heart rate. PCA: pulse contour analysis. GEDVI: global end-diastolic volume index. EVLWI: extra-vascular lung water index. CI: cardiac index.
© Copyright Policy
Related In: Results  -  Collection

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

pone.0153430.g002: Flow-chart of potential comparisons before, during and after renal replacement therapy (RRT).Solid lines are used for comparisons aimed at potential real haemodynamic effects of RRT. Dashed lines are given for comparisons aimed at validation of transpulmonary thermodilution (TPTD) technique. MAP: mean arterial pressure. HR: heart rate. PCA: pulse contour analysis. GEDVI: global end-diastolic volume index. EVLWI: extra-vascular lung water index. CI: cardiac index.
Mentions: To investigate potential confounding and impact of the RRT itself, haemodynamic measurements can be analyzed at a minimum of 6 different times (Table 1; Fig 2): before (T1) and after connection to RRT with (T2on) and without (T2off) blood flow induced by the blood pump as well as before disconnection with (T3on) and without (T3off) blood pump, and finally after disconnection (T4).

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