volume assessment
DESCRIPTION
Volume Assessment. 2010. Old Paradigm. Na + = Volume H 2 O = Tonicity. ICF. ECF. Blood. TBW. Left sided failure DOE Orthopnea 90% sensitivity corr c pcwp PND. Right-sided Failure Abdominal pain Early satiety Nausea/vomiting Non-specific Fatigue Feeling cold Altered mentation. - PowerPoint PPT PresentationTRANSCRIPT
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Volume Assessment
2010
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Old Paradigm
Na+ = Volume
H2O = Tonicity
TBW
ICF ECF
Blood
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Signs & Symptoms: Volume Overload
• Left sided failure– DOE– Orthopnea
• 90% sensitivity corr c pcwp
– PND
• Right-sided Failure– Abdominal pain– Early satiety– Nausea/vomiting
• Non-specific– Fatigue– Feeling cold– Altered mentation
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Physical Exam For Volume Excess States
• Lung ascultation – rales (20% with inc pcwp)
• CVS – S3
• JVP (70% sens/79% spec)– Rondot sign, abd-jugular reflux (inc sens/spec
to 80%) / Valsalva maneuver (82% predictive)
• Edema (50%, less in young adults/children)
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Don’t Forget
• Daily Weight
• I/O???
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JVD
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Laboratory Assessment
• BNP (29pmol/l or 100 pg/ml 96% neg predictive value)
• NT-proBNP (14.75 pmol/l or 125 pg/ml for <75 yo and 53.1pmol/l or 450 pg/ml for >75 100% neg predictive value)
• Nohria et al AmJCard 2005;96:32G
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BNP and PCWP
J Card Fail 2001;7:21
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BNP/proNT-BNP and CKD
Vickery et al. Am J Kidney Dis 46:610
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Bedside Tests
• CXR– Cardiogenic vs.– Non-cardiogenic
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CVP
• CVP corr coef 0.16 with blood vol
• CVP corr 0.18 with stroke index
Osman et al Crit Care Med 2007; 35:64
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Swann vs. Clinician
ESCAPE study Am Heart J 2001;141:528
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PCWP and Volume Expansion
Osman et al Crit Care Med 2007; 35:64
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Bioimpedance
BIG substudy of ESCAPE Am Heart J 2009;158: 217-223
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Where does sodium go?
Heer M, Baisch F, Kropp J, Gerzer R, Drummer C: High dietary sodium chloride consumption may not induce body fluid retention in humans. Am J Physiol Renal Physiol 278:F585
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Skin?
Schafflhuber M, Volpi N, Dahlmann A, Hilgers KF, Maccari F,Dietsch P, Wagner H, Luft FC, Eckardt KU, Titze J: Mobilization of osmotically inactive Na+ by growth and by dietary salt restriction in rats. Am J Physiol Renal Physiol 292:F1490
Dry
Weight
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How can sodium be made osmotically inactive?
Macrophages regulate salt-dependent volume and blood pressure by a vascular endothelial growth factor-C–dependent buffering mechanismAgnes Machnik1, Wolfgang Neuhofer2, Jonathan Jantsch1,3, Anke Dahlmann1, Tuomas Tammela4,Katharina Machura5, Joon-Keun Park6, Franz-Xaver Beck2, Dominik N Mu¨ller7, Wolfgang Derer8,Jennifer Goss1, Agata Ziomber1, Peter Dietsch9, Hubertus Wagner10, Nico van Rooijen11, Armin Kurtz5,Karl F Hilgers1, Kari Alitalo4, Kai-Uwe Eckardt1, Friedrich C Luft7,8, Dontscho Kerjaschki12 & Jens Titze1
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1. High salt diet leads to hypertonic sodium accumulation in
skin via hyperplasia of lymphcapillaries.
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2. Activation of tonicity-responsive enhancer binding protein
(TonEBP) in mononuclear phagocyte system (MPS) cells infiltrating the
interstitium of the skin
LS vs. HS
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3. TonEBP binds the promoter of the geneencoding vascular endothelial growth factor-C
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4. MPS depletion or VEGF-C trapping by soluble VEGF receptor-3
blocks VEGF-C signaling, augments interstitial hypertonic volumeretention, decreases endothelial nitric oxide synthase expression and
elevates blood pressure in response to HSD.
Extracellular volume Intracellular volume
Clondronate liposomes deplete MPS, PBS liposomes were controls
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VEGF-C and Kidneys
H van Goor,H Leuvenink, Kidney International (2009) 75, 767
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New Paradigm
Na+ = Volume
H2O = Tonicity
TBW
ICF ECF
Blood
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