euvolemia: who cares, and why? - amazon web...

Euvolemia: Who cares, and why?

“The cornerstone of critical thinking is the ability to ask questions.”

Dennis Bartels in Scientific American, March, 2013

Anne Diroll, RN, CNN

ANNA, Long Island, N

May 7th, 2014

Place photo here

OBJECTIVES

Upon completion of this educational activity, participants will be able to:

* Avoid the use if high sodium dialysate to prevent an increased risk of LVH, CHF, stroke and death.

* Use goal-directed blood volume reduction when determining adequacy to avoid hyper- and/or hypovolemia.

* Use information other than clinical examinations to assess volume status in dialysis patients so that euvolemia can be achieved.

Per diem Staff Nurse at Rocklin Dialysis (FMC clinic)

and Consultant Human Factors/Usability Testing

Minor Shareholder: XOMA, Keryx

Will not be discussing off-label or investigational use of any pharmaceuticals or medical devices

Email: [email protected]

DISCLOSURE

Do Outcomes Vary by Profit Status? Cohort 150,642 patients

•  For-profit

•  37% higher admission rates for heart failure and volume overload

•  2 LDOs control >2/3 of US facilities

•  Mortality rates higher at for-profits

•  36% ESRD pts dischg’d from an all-cause admit readmitted within 30 days

•  Cause specific: cardiovasc 37%, all infections 34%, access inf 31%

Straub BM.(2014)Do health outcomes vary by profit status of hemodialysis unit? Clin J Am Soc Nephrol 9:1-2. doi: 10.2215/CJN.11891113 Dalrymple, LS et al.(2014) Comparison of hospital rates among for-profit and nonprofit dialysis facilities. Clin J Am Soc Nephrol 9 (1):73-81 doi: 10.2215/CJN.04200413

•  Dissociation of volume & blood pressure

•  Not all low BP is caused by hypovolemia (LVF,LVH)

•  Causes of high BP besides hypervolemia (sympathetic overactivity, arterial stiffness)

•  High BP ≈ hypervolemia - misclassifies 25% of patients

•  Edema - no association between presence or absence of pedal edema & objective markers of volume status

•  echo, BVM, N-terminal-proBNP

Sinha, AD., Agarwal, R. (2009) The Pitfalls of the Clinical Exam in Assessing Volume Status. Sem Dial. Doi: 10.1111/j/1525-139X/2009/0087641.x

The Pitfalls of the Clinical Examination in Assessing Volume Status

Why does volume matter?

Hypovolemia • Sepsis • Overfiltration • Ascites • N/V • Bleeding

Normovolemia • Optimal balance • Regulated by normal

kidney

Hypervolemia • Underfiltration • DW underestimated

Adapted from: Prowle JR et al. (2009). Fluid balance and acute kidney injury, Nat. Rev. Nephrol. 6, 107-115. doi:10.1038/nrneph.2009.213

Organ Dysfunction Adverse Outcomes

Organ Dysfunction Adverse Outcomes

Condition for Coverage

‘manage the patient’s volume status’

§ 494.90(a)(1)

under the “Patient plan of care” condition

www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs

Correlation Grids

V Tag Patient Assessment § 494.80 V Tag Plan of Care § 494.90

V504 BP/fluid management needs V543 Manage BP and volume status

Interdialytic BP & weight gain Target weight Symptoms Value – Euvolemic & BP 130/80

Management of volume status Euvolemic and BP 130/80

V507 Anemia V547 Achieve and sustain Hgb/Hct

Volume Bleeding Infection ESA hypo-response

Hgb on ESAs 10-12 g/dL Hgb off ESAs >10 g/dL

Adapted from: Centers for Medicare & Medicaid Services – Version 1.3

Rates of a CHF diagnosis in ESRD patients Figure 4.5 (Volume 2)

Point prevalent ESRD patients on January 1 of each year: unadjusted USRDS 2013.

CV Mortality Rates are High

USRDS 2011 Annual Data Report, Figure 4.3 (Volume 2)

Period prevalent dialysis patients; unadjusted

12 days / patient year

Hospitalization

USRDS 2012 Annual Data Report, Figure 3.2 (Volume 2)

Increased Hospitalizations

14.3% of Medicare patients hospitalized are for fluid-related diagnosis

Arneson, TJ, Liu, J, Qiu, Y, Gilbertson, DT, Foley, RN, Collins, AJ (2010). Hospital treatment for fluid overload in the medicare hemodialysis population. Clin J Am Soc Nephrol. Jun;5(6):1054-63

Glassock, RJ, Pecoits-Filho, R. & Barberato, SH. (2009). Left ventricular mass in chronic kidney disease and ESRD, Clin J Am Soc Nephrol 4: S79-S91. doi:10.2215/CJN.04860709

¾ of deaths and hospitalizations

in dialysis patients can be linked

to sudden death or CHF, which

are left ventricular in origin

Costs

•  Heart failure was the primary diagnosis in 83% of episodes, fluid overload in 11%, and pulmonary edema in 6%

•  25,291 patients (14.3%) of prevalent Medicare patients experienced 41,699 care episodes over ~2 years

Arneson, TJ, Liu, J, Qiu, Y, Gilbertson, DT, Foley, RN, Collins, AJ. (2010). Hospital treatment for fluid overload in the medicare hemodialysis population. Clin J Am Soc Nephrol. 5(6):1054-63

•  Average cost was $6,372 per episode; total costs were approximately $266 million

Intracellular Volume 28L

Extracellular Volume 11L

Intravascular Volume 5L

Dialysate

Adapted from Ahmad, S. (1999). Fluid Movements in relation to ultrafiltration. In M. Knowles (Ed.), Manual of clinical dialysis (p. 32). London.Science Press Ltd. Bonanno, FG. Hemorrhagic shock: The “physiology approach” J Emerg Trauma Shock. 2012 Oct-Dec; 5(4): 285-295 doi: 10.4103/0974-2700.102357

4-Compartment Fluid Model

70mL/kg Adults

80mL/kg Infants 80 - 90mL/kg Newborns

K+ 140 mEq/L Na+ 12 mEq/L

K+ 3.5 to 5.5 mE/L Na+ 140 mEq/L

K+ 3.5 to 5.5 mE/L Na+ 140 mEq/L

K+ 1-2-3-4 mEq/L Na+ 137 to 154 mEq/L

Effects of Fluid Overload

Increased fluid

LV work

LV hypertrophy & myocardial fibrosis

Heart Failure

RISKS

Arrhythmias MI

SCD IHD

Adapted from: Glassock, RJ, Pecoits-Filho, R. & Barberato, SH. (2009) Left ventricular mass in chronic kidney disease and ESRD, Clin J Am Soc Nephrol 4: S79-S91. doi:10.2215/CJN.04860709

Cerebral edema in hemodialysis

•  Standard intermittent hemodialysis has been repeatedly shown to increase cerebral water content in chronic dialysis patients attending for outpatient treatment

•  During HD water moves back across the blood brain barrier into the cerebral extracellular tissues, where it is initially taken up by the astrocytes and other glial cells causing cell swelling.

•  Rapid passage of bicarbonate into the plasma, with some losses of CO2 into the dialysate, can lead to an imbalance, with the development of a paradoxical intracellular acidosis, due to the transport of CO2 across the blood-brain barrier, which then exacerbates cerebral astrocyte idiogenic osmole generation and increases water uptake by the cells.

Davenport, A. (2008) Practical guidance for dialyzing a hemodialysis patient following acute brain injury. Hemodialysis International. 12:307–312

Adapted from Ahmad, S. (1999). Pathogenic factors contributing to hypertension in renal failure. In M. Knowles (Ed.), Manual of clinical dialysis (p. 112). London: Science Press Ltd.

Volume excess

Hypertension

Essential Hypertension

Renin-Angiotensin-Aldosterone

Endothelin, NO, etc. Erythropoetin

Na+/K+ -ATPase inhibitors

Toxin(s)

Sympathetic activity

Parathyroid hormone/Ca2+

Factors Affecting HTN in Renal Failure

Volume-Dependent Hypertension in Hemodialysis

Therapeutic Interventions •  Prudent diet

•  Volume reduction

•  Achieve dry weight

•  Low sodium bath

•  Ultrafiltration

85-90% HTN is volume

dependent

Mailloux, LU, Bellucci, AG, Napolitano, B & Mossey, RT. (1994). The contribution of hypertension to dialysis patient outcomes. ASAIO Journal. 40(2):130-137.

Antihypertensives: Hypertension & Hypotension - The Vicious Cycle – 1994

Interdialytic weight gain

Dry weight never achieved

Minimal weight loss

Dialysis-induced hypotension (autonomic and/or V. dysfunction?)

Normotension

LVH on ECHO?

Antihypertensive drugs

Predialysis hypertension

Volume repletion

Adapted from: Mailloux, LU, Bellucci, AG, Napolitano, B & Mossey, RT. (1994). The contribution of hypertension to dialysis patient outcomes. ASAIO Journal. 40(2): p.134.

•  Hypervolemia dilutes Hgb AND Hct

•  Current ESA therapy does not account for volume

•  Hypervolemia increases inflammation

Anemia: Achieving & Sustaining Hgb/Hct

Reyes-Bahamonde J, Raimann JG, Thijssen S, Levin NW, & Kotanko P. (2013) Fluid Overload and Inflammation—A Vicious Cycle. Seminars in Dialysis Vol 26, No 1 (January–February) pp. 16–39 DOI: 10.1111/sdi.12024

Pecoits-Filho, R et al. (2004). Impact of residual renal function on volume status in chronic renal failure. Blood Purif. 22(3):285-92.

Amgen Package insert.

33%

•  Inflammation contributes to ESA resistance

Effects of Fluid Deficit

•  Access Complications

•  Myocardial Stunning/Cardiac Ischemia

•  Stroke risk/leukoaraiosis

•  Loss of residual renal function

•  Hypotension/Hypertension

•  Cramping/Nausea/Vomiting

•  top causes of early sign-offs

•  leads to decreased adequacy

Over

Ultrafiltration &

hypoperfusion

McIntyre, CW. (2009). Effects of hemodialysis on cardiac function. Kidney Int. 76(4):371-375.

Stevens, LA, Viswanathan G, Weiner, DE. (2010). CKD and ESRD in the Elderly: Current Prevalence, Future Projections, and Clinical Significance. Adv Chronic Kidney Dis. July ; 17(4): 293–301. doi:10.1053/j.ackd.2010.03.010

Brewster, UC, Perazella, MA. (2004). Cardiorenal effects of the renin-angiotensin-aldosterone system. Hospital Physician. Jun;40:11-20.

Rocco, MV & Burkart, JM. (1993). Prevalence of missed treatments and early sign-offs in hemodialysis patients. JASN. Nov:4(5):1178-1183.

Cerebral blood flow in hemodialysis patients

•  Cerebral blood flow decreases with age.

•  Studies in healthy nonanemic hemodialysis patients have shown that cerebral blood flow is either normal or decreased, with reduced regional cortical oxygen supply.

•  During hemodialysis, middle cerebral blood flow falls with increasing ultrafiltration1

Davenport, A. (2008) Practical guidance for dialyzing a hemodialysis patient following acute brain injury. Hemodialysis International. 12:307–312 1Stefanidis I, Bach R, Mertens PR, et al. (2005) Influence of hemodialysis on the mean blood flow velocity in the middle cerebral artery. Clin Nephrol. 64:129–137

Myocardial Stunning and Ischemia

Increased Troponins • cTn1 rose significantly when measured 44 h. after

dialysis sessions complicated by IDH • Elevated levels predict mortality

Silent ST Depression • Subclinical ischemia • W/O plaque rupture • First reported in 1989 • Reported as 15-40% occurrence

Loss of Contractile Function • Dialysis-induced myocardial stunning associated

with increased rate of intradialytic and post dialytic ventricular arrhythmias

Cardiac Remodeling • LVH (75% of pts on dialysis) • Reduced arterial compliance • Impaired microcirculation

Intradialytic Hypotension (20-30% occurrence)

UF Rate

McIntyre, CW. (2009). Effects of hemodialysis on cardiac function. Kidney Int. 76(4):371-375

Myocardial Stunning

myocardial hibernation

myocardial remodelling

scarring

Loss of contractile function

Aberrant electrical conductivity

sudden death

Zuidema, MY & Dellsperger, KC. (2012) Myocardial stunning with hemodialysis: Clinical challenges of the cardiorenal patient. Cardiorenal Med. May 2012; 2(2): 125-133 Hothi, DK et al. (2009) Pediatric myocardial stunning underscores the cardiac toxicity of conventional dialysis treatments. Clin J Am Soc Nephrol 4: 790-797.

Probability of sudden cardiac death in 2010 incident dialysis patients, by race Figure 4.10 (Volume 2)

Incident dialysis patients; simple method. USRDS 2013

Current Treatment

êBP •  Normal Saline1

•  Decrease UFR

•  Trendellenberg2

•  Broth, pickles3

éBP •  Clonidine

•  Increase UFR

1Standing orders. LDOs 2Shem, Samuel. (1978) House of God. Random House, New York 3Anonymous Clinic, somewhere in America…

Nancy, RN

Dallas QI, 2012 – Goals of Therapy

•  ECV control using assistive technology

•  Normalized ECV

•  Prevent intradialytic hypotension and cardiac stunning through controlled ultrafiltration

•  Reduce volume-related hospitalizations

Parker III, T.F. et al. (2013) A quality initiative: Reducing rates of hospitalizations by objectively monitoring volume removal. Nephrology News and Issues. Mar;27(3): 30-36

Tools to Improve Safe Fluid Removal

•  Education

•  Assistive Technology

H.D.

urea

Sinha, AD (2011). Why assistive Technology is needed for probing of dry weight. Blood Purification, 31: 197-202. DOI: 10.1159/000321840

Quality Initiative Protocol: Assess Two Techniques to Control ECV

Education Only Group •  Eight (8) facilities

•  Educational program for physicians, staff, and patients

•  Show necessity for volume control

•  Salt restriction

•  Clinical assessment of dry weight

Education and Intervention Group •  Seven (7) facilities

•  Oxygen saturation

•  Control intradialytic ECV to gain optimal volume removal and prevent symptoms

•  Establishment of normalized ECV using assistive technology


•  Extra Tx for fluid removal prn

Education

•  No sodium modeling

•  Dialysate sodium 138 mEq/L

•  Focused review of sodium content in food

•  Dialysate T 36° C

•  Max UFR of 13 mL/Kg/hour

•  Fluid assessment and the importance of proper fluid management

•  4-hour Tx time

•  Update Med lists

•  All Physicians, Dieticians, RNs

Cool Dialysate

•  Most patients benefited from cold dialysate (34.5°C) for prevention of hypoxia1

•  Dialysate temp 36.4 to 35.8°C adjusted by blood temperature monitor.

•  Patients had less symptomatic hypotension, nausea, infusions and meds for morbid events2

1 Hegbrant J et al (1997). Beneficial effect of cold dialysate for the prevention of hemodialysis-induced hypoxia. Blood Purification, 15(1):15-24. 2 Veljančić, L., et al. (2011) Simultaneous blood temperature control and blood volume control reduces intradialytic symptoms. Int J Artif Organs 2011; 34(4): 357-364

Individualized Dialysate Temperature: Compare LV regional wall motion abnormalities with ECHOs pre-HD, 2h, 4h (peak stress) and 30” into recovery

Standard 37°C

•  Pre-dialysis temp 36.1 (±0.6)°C

•  CO & Total Peripheral Resistance did not change

•  Mean number of regional wall motion abnormalities per patient at peak stress significantly higher

Individualized

•  Pre-dialysis temp 36.0 (±0.5)°C

•  Mean intradialytic BP higher

•  CO decreased and Total Peripheral Resistance increased

Jeffries, HJ., Burton, JO., McIntyre, CW. (2011) Individualized Dialysate Temperature Improves Intradialytic Haemodynamics and Abrogates Haemodialysis-Induced Myocardial Stunning, without Compromising Tolerability. Blood Purif 2011; 32: 63-68

Dialyzing patients at their body temperature seems to be effective, simple and cost-free.

Implications of current trend toward prescribing high dialysate sodium in HD

Santos, SFF & Peixoto, AJ. (2008). Revisiting the Dialysate Sodium Prescription as a Tool for Better Blood Pressure and Interdialytic Weight Gain Management in Hemodialysis Patients. Clin J Am Soc Nephrol. Doi:10.2215/CJN.03360807

HYPERNATRIC DIALYSATE

Decreased sodium removal

Volume overload

Increased serum sodium

Increased thirst

Hypertension LVH, CHF, Stroke,

Death

Dialysate Sodium & Sodium Gradient

•  1,084 clinically stable HD patients

•  Dialysate sodium 136-149 mEq/L

•  Mean pre-HD plasma Na+ 136.7 (+/- 2.9 mEq/L)

•  83% patients dialyzed against a positive Na+ gradient

•  Mean Na+ gradient 4.6 (+/- 4.4mEq/L)

•  Plasma Na+ increased in 91% patients

•  Mean post-HD Na+ 141.3 (+/- 2.5mEq/L)

Mendoza JM, Sun S, Chertow GM, Moran J, Doss S, Schiller B. (2011)

Dialysate sodium and sodium gradient in maintenance hemodialysis: a neglected sodium restriction approach?

Nephrol Dial Transplant 26: 1281-1287 doi: 10.1093/ndt/gfq807

Thirst

•  Post-HD thirst directly correlated with sodium gradient

Mendoza JM, Sun S, Chertow GM, Moran J, Doss S, Schiller B (2011)



Sodium Burden

Mendoza JM, Sun S, Chertow GM, Moran J, Doss S, Schiller B. (2011)



Intrinsic Causes of Hypotension

•  Diabetic hypotonia due autonomic dysfunction, neuropathy, hypoglycemia •  Uremia – independent risk factor for autonomic dysfunction •  CV disease – atherosclerosis, CAD, LVH, arrhythmias, valvular disease, pericardial

disease, cardiac underfilling •  Sepsis •  GI bleed •  Hypoalbunemia2 •  Anemia2 •  Chronic inflammation3 •  Vaso-active substances: •  i)Nitric Oxide high levels = rapid vasodilation; •  ii) Adenosine released during tissue ischemia – hypoxia. Dialysis patients have

high adenosine levels. Adenosine suppresses cardiac contractility, causes artery relaxation.

Sulowicz, W., Radziszewski, A. (2006) Pathogenesis and treatment of dialysis hypotension. Kidney International 70,S36-S39 2KDOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients. Section III. © 2005 NKF 3Sklar et al 1999 Am J Kidney Dis 34: 464-470

Treatment for Hypotension •  Fluids: Normal Saline, mannitol, albumin •  Trendellenberg •  Limit interdialytic weight gain •  No eating just before and during dialysis •  No overdosing of anti-hypertensives •  Cool dialysate •  Isothermic – BTM – modifies dialysate temperature •  Midodrine •  Serotonin Reuptake Inhibitors •  FK352 – adenosine α1 receptor antagonist •  L-arginine supplements •  Carnitine – because deficiency leads to ESA-resistance and

hypotonia •  Oxygen •  Blood Volume Monitoring •  Bioimpedance •  Short, daily hemodialysis

Sulowicz, W., Radziszewski, A. (2006) Pathogenesis and treatment of dialysis hypotension. Kidney International 70,S36-S39

Fluid to treat BP

• Asymptomatic

• Low BP

FLUID

• Due to valvular or myocardial pathology

• Ventricles have decreased functional reserve

FLUID OVERLOAD • Low cardiac output

• Cardiac Failure • Treatment of one

condition worsens the other

• Gut edema

CIRCULATORY SHOCK

Bonanno, FG. (2012). Hemorrhagic shock: The “physiology approach”. J Emerg Trauma Shock. Oct-Dec; 5(4): 285-295 doi: 10.4103/0974-2700.102357

Education + Assistive Technology

•  < 3% per hour volume reduction = increase UF goal by 200 mL per Tx

•  3 - 8% per hour volume reduction (not to exceed 15% total) = No change

•  > 8% per hour volume reduction = decrease UF goal

•  Oxygen supplementation for SaO2 of < 90% or SvO2 of < 60%

•  Refill Assessment: If refill is present, add 200 mL to UF goal next Tx

Hypoxia Definition

“An inadequate supply of oxygen to tissues is called tissue hypoxia”

West, JB (1985). Gas transport to the periphery. In TM Tracy (Ed.), Respiratory physiology-‐the essentials. p. 83.

Baltimore, MD: Williams & Wilkins

Glennie, JA. (2013) Architecture student. UT, Austin,TX. Art used with permission

Gheuens, E.O., Daelemans, R., & De Broe, M.E. (2000). Pulmonary problems in hemodialysis and peritoneal dialysis. In N. Lameire & R.L. Mehta (Eds.), Complications of dialysis (pp. 485-491). New York, NY: Marcel Dekker, Inc.

Incidence

•  Hypoxemia occurs in nearly 90% of patients during hemodialysis, may contribute to intradialytic hypotension, nausea, and muscle cramps

•  Pleural effusion present in 28% of pre-dialysis chest radiographs

•  Soft tissue calcification was identified in 79% of patients on hemodialysis – heart, lungs, stomach

•  Functional pulmonary changes

•  Sleep apnea 60% ESRD patients, contributing to arrhythmias and pulmonary HTN

Hypoxia Causes

Guyton, AC & Hall, JE (2000). Respiratory insufficiency – pathophysiology, diagnosis, oxygen therapy. In A Norwitz (Ed.), Textbook of medical physiology (pp. 490-491). Philadelphia, PA: Saunders.

West, JB (1985). Gas transport to the periphery. In TM Tracy (Ed.), Respiratory physiology-the essentials (p. 83). Baltimore, MD: Williams & Wilkins.

• Pulmonary • Hypoventilation HYPOXIC

• ↓ Hemoglobin = hypoxemia • Dilutional d/t hypervolemia ANEMIC

• ↓ Cardiac Output • Hypovolemia CIRCULATORY

• Sepsis • Toxic Substances HISTOTOXIC

Hypoxia

Vasodilation

Hypotension

↓ UFR Saline Bolus

Volume Overload

Anemia CP

Complications

Thorn, C.E., Kyte, H., Slaff, D.W. & Shore, A.C. (2011). An association between vasomotion and oxygen extraction. American Journal of Physiology Heart and Circulatory Physiology, 301(2): H442-H449.

Gheuens, EO et al (2000). Pulmonary problems in hemodialysis and peritoneal dialysis. In N. Lameire & R.L. Mehta (Eds.), Complications of dialysis (pp. 485-491). NY, NY: Marcel Dekker, Inc.

Diroll, DD (2013). Oxygen as an adjunct to treat intra-dialytic hypotension during hemodialysis. Manuscript submitted for publication.

Elapsed Time Blood Pressure Pulse BV ∆ Oxygen Saturation Intervention

0:00 112/63 61 0.0% 82.3% HD commenced

0:30 86/46 62 -2.0% 85% O2 @ 2L per nasal cannula 0:40 97/51 62 -0.5% (refill) 94% UF Goal increased from 3.0L to 4.9L

1:00 108/51 65 -1.5% 94%

1:15 118/56 66 -2.0% 94%

1:30 140/72 69 -2.0% 95%

2:00 136/78 70 -2.5% 94%

2:30 125/64 71 -4.5% 90%

3:00 137/74 71 -5.0% 93%

3:30 125/68 72 -7.3% 92%

4:00 -7.3% 93% HD ended

Case Study Monitor-Guided Interventions

Diroll, DD (2013). Oxygen as an adjunct to treat intra-dialytic hypotension during hemodialysis. Manuscript submitted for publication.

SvO2 Monitoring is a big deal…

Hemodynamic Monitoring made Incredibly Visual (2006): Lippincott Williams & Wilkins. Ch 7 Cardiac Output Monitoring. Pg 112.

…because it allows rapid detection of impaired oxygen delivery…

such as from decreased Cardiac Output

Cardiac Output is a big deal because…

BP = CO X SVR

ScvO2 predicts hypotension

Normal ScvO2 ≈ 75%

Range ≈ 60 to 80%

A drop of 5 to 7 % points from patient’s baseline is significant1

Cardiac Output = O2 uptake/SaO2 – ScvO2

∴↓ScvO2 = ↓CO = ↓BP (BP = CO X PVR)

Caveat: ScvO2 decreases with movement, fever, seizures, and suctioning. Patient should be calm and still when you evaluate ScvO2 in relation to BP.

Hothi, DK., et al (2009) Pediatric Myocardial Stunning Underscores the Cardiac Toxicity of Conventional Hemodialysis Treatments Clin J Am Soc Nephrol 4: 790 –797. doi: 10.2215/CJN.05921108. 1Cordtz J., et al (2008) Central venous oxygen saturation and thoracic admittance during dialysis: New approaches to hemodynamic monitoring. Hemodialysis International; 12:369-377 Bauer P, Reinhart K, Bauer M (2008). Significance of venous oximetry in the critically ill. Med Intensiva.;32(3):134-42

Fluid-Related Hospitalizations

Hospitalizations (per 1000

treatments)

Hospitalizations (per patient-

year)

Hospitalized days

(per 1000 treatments)

Hospitalized days

(per patient-year)

Before After Before After Before After Before After

Education & Assistive Technology

1.02 0.53 0.16 0.08 4.17 1.83 0.65 0.29

Education Only 0.99 1.04 0.15 0.16 4.5 5.54 0.70 0.86

Parker III, T.F. et al.(2013) A quality initiative: Reducing rates of hospitalizations by objectively monitoring volume removal. Nephrology News and Issues. Mar;27(3): 30-36

All-Cause Hospitalizations

Hospitalizations (per 1000

treatments)

Hospitalizations (per patient-

year)

Hospitalized days

(per 1000 treatments)

Hospitalized days

(per patient-year)

Before After Before After Before After Before After

Education & Assistive Technology

13.87 10.45 2.16 1.63 72.68 64.26 11.34 10.03

Education 11.09 10.68 1.73 1.67 66.35 66.38 10.35 10.35

Parker III, T.F. et al.(2013) A quality initiative: Reducing rates of hospitalizations by objectively monitoring volume removal. Nephrology News and Issues. Mar;27(3): 30-36

Results

•  Results suggest substantial reduction in ECV-related hospitalizations using objective monitoring of ECV removal and attainment of “normalized ECV” versus education only intervention

•  Statistically significant for all-cause hospitalizations

•  Approaching statistical significance for fluid-related events and fluid-related hospitalized days

•  Conventional education and assessment of “dry weight”, in this study, does not appear to be effective


Conclusion

1.  Move from a Kt/V model to a Kt/V + volume removal prescriptive model

2.  Contemporary management, which is dependent on a clinically derived estimate of dry weight, leads to both an overestimation and underestimation of dry weight

3.  Future work should focus on the impact of uremic toxin clearance and volume control as critical components of the measurement of dose of dialysis

Parker III, T.F. et al. (2013) A quality initiative: Reducing rates of hospitalizations by objectively monitoring volume removal. Nephrology News and Issues. Mar;27(3): 30-36 Jaeger & Mehta (1999): Assessment of dry weight in hemodialysis. JASN, 10:392-403, Ahmad, S. (1999). Dose of hemodialysis. In M. Knowles (Ed.), Manual of clinical dialysis (p. 52). London: Science Press Ltd.

What’s good for the heart is good for the brain – assistive technology

•  Continuous O2 sat monitoring •  Evaluate ScvO2

•  Hypoxia Avoidance •  BVM to set accurate DW •  Revascularization – PTCA, stents, CABG •  More frequent HD •  Convert to PD •  Cool dialysate •  Thermoregulaltion •  Dialysate magnesium manipulation •  Individualized Sodium Dialysate

Sinha, AD (2011). Why assistive Technology is needed for probing of dry weight. Blood Purification, 31: 197-202. DOI: 10.1159/000321840 McIntyre, CW. (2009) Effects of hemodialysis on cardiac function. Kidney Int. 76(4):371-375 Cordtz J., et al (2008) Central venous oxygen saturation and thoracic admittance during dialysis: New approaches to hemodynamic monitoring. Hemodialysis International; 12:369-377

ADDITIONAL OBJECTIVE

If we have time…

Discuss the dissociation between pressure and volume

Smith JJ, Kampine JP.(1990) Circulatory Physiology-the essentials. 3rd ed. Ch 1. Blood and the Circulation. Page 10. Williams & Wilkins, Baltimore

Pressure and volume distribution in the systemic circulation. Note the inverse relationship between internal pressure and volume in different portions of the circulatory system

Change in BV does not mirror intradialytic changes in BP

•  72 stable adult outpatients

•  BV measurement was 91.6% (+/- 0.6)

•  BV measurement had no relationship with pre-, intra- or postdialysis blood pressure recordings

•  Did correlate with a postdialysis change in extracellular fluid volume

Booth J, Pinney J, Davenport A: Do changes in relative blood volume monitoring correlate to hemodialysis-associated hypotension? Nephron Clin Pract. 2011;117(3):c179-83. doi: 10.1159/000320196. Epub 2010 Aug 30

Plasma Volume (PV) & BP

Design

•  60 non-diabetics

•  Excluded if Plasma Refill Rate affected (cardiac)

•  Hypertensive (n=26) ΔPV% 12.9 (±7.3)

•  Normotensive (n=34)ΔPV% 12.5 (±6.6)

Conclusions

•  Relationship between BP & volume not linear

•  Could not find correlation between Δ in BW & SBP

•  No correlation between intradialytic Δ in PV, BW & alterations of SBP or DBP during HD

Khalaj,A-R., Sanavi, S., Afshar, R., Rajabi, M-R (2010) Effect of Intradialytic Change in Plasma Volume on Blood Pressure in Patients Undergoing Maintenance Hemodialysis.J Lam Physicians. Jul-Dec; 2(2): 66-69. doi: 10.4103/0974-2727.72151

Non-invasive monitoring of hemodynamic variables

•  Impedance cardiography (IPG-104 Mini-Lab®)

•  EKG lead I

•  MAP – cuff sphygmanometer

•  BVM (Crit Line®)

•  CO calculated (SV X HR)

•  SVR calculated(MAP/CO)*80

•  Degree hypovolemia seems not to play a key role in the origin of acute intradialytic hypotensive episodes

Straver, B. (2005) Hypotension during hemodialysis. © B.Straver, Amsterdam, the Netherlands. ISBN 90 6464 5 51 5. Ch 2. Systemic Vascular Resistance in intradialytic hypotension determined by means of impedance cardiography.

34% hypotensive episodes in PICU No difference between BVM & Control Groups

•  Hypotension 33% in BVM group

•  Hypotension 36% in control group

•  Mean UF significantly higher in BVM group 48 vs. 33 mL/kg

•  Mean decrease in BV did not exceed 13% over entire session in patients without hypotension

•  The use of BVM allowed a higher UF rate without influencing the frequency of hypotensive episodes

Median age 11 yo

(1.8 to 18)

Body Weight

36 Kg

(10-85)

70 patients with

Blood Volume Monitoring

(BP+HR+BVM)

64 patients without


(BP+HR)

AKI

Merouani, A., et al. (2011) impact of blood volume monitoring on fluid removal during intermittent hemodialysis in critically ill children with acute kidney injury. Nephrol Dial Transplant (2011) 26: 3315-3319 doi: 10.1093/ndt/gfq855


•  Does it reduce episodes of IDH? Does it predict IDH?

•  No!1

•  IDH occurs when cardiovascular compensatory mechanisms can no longer compensate for the reduction in blood volume

•  Yes!2

•  By means of continuous and automatic control of BV, it is possible to reduce the incidence of hypotension during hemodialysis in patients suffering from this disorder2

59

1Micklos, L. Does Blood Volume Monitoring Use Decrease Episodes of Intradialytic Hypotension in Chronic Hemodialysis Patients? (2013) Neph Nurs J Sept-Oct Vol.40, No.5 2Santoro, A., et al, (2002) Blood volume controlled hemodialysis in hypotension-prone patients: A randomized, multicenter controlled trial. KI 62, 1034–1045; doi:10.1046/j.1523-1755.2002.00511.x Dasselaar, JJ., Huisman, RM., de Jong, PE., Franssen, CFM. (2005) Measurement of relative blood volume changes during hemodialysis: Merits and limitations. NDT 20, 2043-2049

Central Venous Pressure

•  Review - very poor relationship between CVP and blood volume as well as inability of CVP/CVP to predict hemodynamic response to a fluid challenge.

•  CVP is a measure of right atrial pressure alone; and not a measure of blood volume or ventricular preload.

•  CVP should not be used to make clinical decisions regarding fluid management

Marik, PE., Baram, M., Vahid, B.: (2008) Does Central Venous Pressure Predict Fluid Responsiveness? CHEST; 134:172–178)

No correlation observed between drop in Blood Volume and drop in MAP

Drop in Stroke Volume

•  ΔCO had a strong significant correlation with ΔMAP

Fall in Systemic Vascular Resistance

•  Severe inappropriate vasodialtion

•  Decrease in sympathetic tone during HD

•  Nitric Oxide release

Straver, B. (2005) Hypotension during hemodialysis. © B.Straver, Amsterdam, The Netherlands. ISBN 90 6464 5 51 5. Ch 3. A new classification of intradialytic hypotension. Ch 4. Clinical reproducibility of intradialytic hypotension characteristics.

3 groups – Non-H/SVR-H/SV-H. No differences in tissue hydration. ΔBV not a

statistically significant determinant of BP, while ΔSV was. Intra-individual

reproducibility of cause of IDH clear in 70% of hemodialysis patients.

INTERPRETIVE GUIDANCE

•  Because of the adverse effects of ESRD, many patients experience lability of blood pressure and fluid management, the management of which may require reassessment of medication needs, adjustments in target weight, and changes to the POC.

•  The comprehensive assessment should include evaluation of the patient’s pre/intra/post and interdialytic blood pressures, interdialytic weight gains, target weight, and related intradialytic symptoms (e.g., hypertension, hypotension, muscular cramping) along with an analysis for potential root causes.

•  For pediatric patients weighing less than 35 kg., blood volume monitoring during hemodialysis should be available in order to evaluate body weight changes for gains in muscle weight vs. fluid overload.

CfC TAG NUMBER: V504 REGULATION: Blood pressure, and fluid management needs.

(pg 189 of 299. October 2008) www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGeninfo/downloads//SCletter09-01.pdf

Blood Pressure

BP = Cardiac Output X Peripheral Vascular Resistance

Smith & Kampine: Circulatory Physiology - the essentials 3rd edition Williams & Wilkins 1990.

Sinha AD, Agarwal R (2009) The Pitfalls of the Clinical Examination in Assessing Volume Status. Seminars in Dialysis DOI: 10.1111/j/1525-139X/2009/0087641.x

Brewster, UC, Perazella, MA (2004) Cardiorenal Effects of the Renin-Angiotensin-Aldosterone System, Hospital Physician, June, pp. 11-20.

Diroll A, Hlebovy D (2003) Inverse relationship between blood volume and blood pressure. Nephrol Nursing J 30:460-461,

Hypovolemia = BP or BP

Hypervolemia = BP or BP

Mosaic Octagon of Blood Pressure

Adapted from Page, I.H., Circ Res 34:133, 1974

Interventions to Prevent Hypotension

Dialysis-based

Daily HD Thermoregulation

O2 Therapy/Hypoxia

Avoidance

Dialysate Na+ of 138 mEq/L

pH/Bicarb Slower UFR

Non Dialysis-based

Dietary Na+ Reduction Diabetes Control

McIntyre, CW. (2009). Effects of hemodialysis on cardiac function. Kidney Int. 76(4):371-375

Ahmad, S. (1999). Complications of hemodialysis. In M. Knowles (Ed.), Manual of clinical dialysis (p. 35). London: Science Press Ltd.

Quotable quotes

•  There are no randomized controlled trials among patients on conventional hemodialysis to help identify goal BP targets

•  Much uncertainty remains regarding the ideal BP to improve outcomes among patients on 3X/week conventional hemodialysis

•  CMS bases dialysis adequacy solely on urea removal. Factors such as BP control, attainment of euvolemia, and ensuring isonatric dialysis are not captured nor incentivized.

Inrig, JK.(2013) Peridialytic hypertension and hypotension: another U-shaped BP-outcome association. KI 84, 641-644. doi:10.1038/ki.2013.247

?Target BVR

1Flat slope = BVR 0.3% to 1.1% per hour 1.72 higher hazard of mortality

1Agarwal, R. (2010) Hypervolemia is associated with increased mortality among hemodialysis patients. Hypertension. Jul; DOI: 10.1161/HYPERTENSIONAHA.110.154815 2Sinha, AD, Light, RP, & Agarwal, R.(2009) Relative plasma volume monitoring during hemodialysis aids the assessment of dry weight. Hypertension. Dec. DOI:10.1161/HYPERTENSIONAHA.109.143974

1Steep slope = BVR 1.6% to 3.6% per hour

Examples: 3-hour run, total BVR = 4.8 to 10.8% 4-hour run, total BVR = 6.4 to 14.4%

Improvements: 2BP reduction

1higher albumin level

1higher Hgb

The End!

Content Anne Diroll,

RN, CNN

Formatting & Graphics Daniel Diroll,

BS (Phys Ed)

MA (Kinesiology)

BSN, RN

euvolemia: who cares, and why? - amazon web...

Documents