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Abstract
BackgroundTreatment of multiple organ failure frequently requires enhanced hemodynamic monitoring. When renal replacement is indicated, it remains unclear whether transpulmonary thermodilution (TPTD) measurements are influenced by renal replacement therapy (RRT) and whether RRT should be paused for TPTD measurements. Our aim was therefore to investigate the effect of pausing RRT on TPTD results in two dialysis catheter locations.Materials and methodsIn total, 62 TPTD measurements in 24 patients (APACHE: 32 ± 7 [mean ± standard deviation (SD)]) were performed using the PiCCO™ system (Pulsion, Germany). Patients were treated with sustained low efficiency dialysis (SLED; Genius™ system, Fresenius, Germany) as RRT. Measurements were taken during ongoing hemodialysis (HD, HDO), during paused HD (HDP) and immediately after termination of HD and blood restitution (HDT). Dialysis catheters were placed either in the superior vena cava (SVC, 19 times) or in the inferior vena cava (IVC, 5 times). Statistical analysis was performed to assess the effects of the measurement setting, SLED (blood flow rate) and the catheter location, on cardiac index (CI), global end-diastolic volume index (GEDVI) and extravascular lung water index (EVLWI) as measured by TPTD. Multilevel models were used for the analysis due to the triplicate measurements and due to 12 out of 19 SVC and 2 out of 5 IVC patients having more than one TPTD measured.ResultsCI and GEDVI were significantly higher at time point HDP compared to both HDO and HDT. In contrast, values for EVLWI were lower at HDP when compared to HDO and HDT. These findings were independent of the site of dialysis catheter insertion and blood flow rate.ConclusionsPiCCO™ measurements assessed at paused SLED significantly deviate from ongoing and terminated SLED. Therefore, the dialysis system should not be paused for measurements. TPTD measurements in patients with PiCCO monitoring seem sufficiently reliable during ongoing SLED as well as after its termination. An effect of dialysis catheter location (SVC vs IVC) and blood flow rate on PiCCO™ measurements could not be shown.
Highlights
Treatment of multiple organ failure frequently requires enhanced hemodynamic monitoring
transpulmonary thermodilution (TPTD) measurements in patients with PiCCO monitoring seem sufficiently reliable during ongoing sustained low efficiency dialysis (SLED) as well as after its termination
The mean absolute values for ongoing hemodialysis (HDO) and HD and blood restitution (HDT) were in the same range, whereas the results differed from paused hemodialysis (HDP)
Summary
Treatment of multiple organ failure frequently requires enhanced hemodynamic monitoring. Techniques like indicator dilution are considered as most appropriate and can be obtained either by pulmonary arterial catheter or by transpulmonary thermodilution (TPTD) [1, 2]. Since up to 30% of critically ill patients with multiple organ failure (MOF) develop acute kidney injury (AKI), 10% of them will require renal replacement therapy (RRT) [3]. There are other potential confounders of the RRT on thermodilution: loss of indicator in the circuit, changes in blood pump flow and an immediate proximity of the central venous catheter (CVC) and dialysis catheter (e.g., both catheters in jugular veins or both catheters in the femoral veins), which might impair TPTD by withdrawing the fluid bolus injected via the CVC via the dialysis catheter [3]
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