Blood Volume Status Research Articles

PO-0329 Multimodal Haemodynamic Monitoring (hsm) For The Manegement Of Acute Circulatory Failure (acf) In Paediatric Intensive Care Unit (picu)

Background and aims Multimodal haemodynamic monitoring has an important role in PICU, because that can aid the intensivist to perform the management of children with acute circulatory failure. The aim is to improve the interest of haemodynamic management with multimodal parameters to answer to the 3 most commonly asked questions: Complete clinical diagnosis, guide therapeutics, and repeat measures for evaluation. Methods In this prospective study, between January 2012 and April 2014, the assessment of haemodynamic was obtained progressively by NIBP, TTE, and estimated continuous cardiac output (esCCO), and/or Oesophageal Doppler, an/or pleth variability index (PVI) for each patient with ACF. Results On a total of 33 patients with ACF, all patients was treated: - Volume expansion in 31 patients « fluid responsiveness based on the respiratory variation aortic flow peak velocity Δ Vpeak ao, SV, and inferior vena cava, and/or PVI, FTc, Δ Vpeak by OD . 29 responder (Δ SV ≥ 10% by TTE, esCCO and/or OD). 2 non responder (Δ SV - Norepinephrine was introduced in 14 patients (objective MAP and or PPC for SPTBI), 2 of them had a profound vasoplegia « DAP - Dobutamine was introduced in 2 patients with LVEF Conclusion MHM allows optimisation of systemic haemodynamic: assessment of CO, blood volume status, vascular resistance and contractility.

Assessment of cardiac output and volume load by transpulmonary thermodilution technique in immature pigs.

To assess the accuracy of cardiac output (CO) measured by transpulmonary thermodilution technique (TPTD)and explore the validity of intrathoracic blood volume index (ITBVI) for assessment of circulatory volume status. Ten immature pigs with a mean weight of (20.6±1.9)kg were studied during the conditions including normovolemia, hypervolemia, and hypovolemia. Simultaneous CO was measured in each condition using pulmonary artery thermodilution (PATD) method and TPTD. More specifically, CO (COPA) was determined with PATD, while CO (COTP) and ITBVI were determined with TPTD. All measurements were repeated 3 times. Central venous pressure (CVP) and heart rate were measured at the same time. The potential correlations of CVP and ITBVI with cardiac index (CI) and stroke volume index (SVI) in each blood volume status were analyzed. A total of 90 simultaneous measurements of COPA and COTP in 3 different blood volume conditions were made. The correlation coefficient between the two measurements was 0.977 (P<0.001) and the mean difference was (0.25±0.26)L/min (95%CI:0.20-0.30 L/min, P<0.001). The coefficient of variation of COTP was 3.7%, while COPA was 5.4%. Compared with those in normovolemia, CVP and ITBVI in hypervolemia significantly increased (P=0.002, 0.019), ITBVI in hypovolemia decreased significantly (P<0.001), and CVP in hypovolemia decreased insignificantly (P=0.05). Correlation analysis revealed a significant correlation between ITBVI with CI and SVI in normovolemia (r=0.741, P=0.014; r=0.885, P=0.001). In contrast, correlations between CVP with CI and SVI were poor. TPTD can accurately and precisely measure CO in different blood volume conditions. ITBVI measured by TPTD has better validity for the assessment of circulatory volume status than CVP.

Association between bioimpedance analysis parameters and left ventricular hypertrophy in peritoneal dialysis patients

Chronic volume overload, hypertension and left ventricular hypertrophy are major risk factors contributing to the high mortality rate in peritoneal dialysis (PD) patients. In this study, we aimed to determine the impact of blood pressure measurements and volume status determined by bioelectrical impedance analysis (BIA) measurements over left ventricular hypertrophy (LVH) in PD patients. Thirty-one prevalent PD patients were enrolled. Patients with a documented cardiovascular disease and uncontrolled hypertension were excluded. BIA and transthoracic echocardiography were performed in all patients All measurements were taken with the empty abdominal cavity. Routine laboratory parameters were also assessed in all patients. Extracellular water (ECW) in liters and ECW/total body water (TBW) ratio were used for determining volume status. Mean age of the patients was 43.9 ± 15.4 years, and mean PD duration was 39.5 ± 29.6 months. Mean ECW/TBW ratio was 44.3 %. Left ventricular mass index (LVMI) was 134.3 ± 34.9 g/m(2). Fifty-eight percent of patients had LVH. Mean LVMI was negatively correlated with daily urine volume (r -0.568, p 0.001) and weekly Kt/V (r -0.393, p 0.029); positively correlated with daily ultrafiltration (r +0.585, p 0.001) and office systolic (r +0.500, p 0.004) and diastolic (r +0.459, p 0.009) blood pressures. In linear regression analysis, daily urine volume (B -0.426, p 0.002) mean diastolic blood pressure (B 0.550, p <0.001), ECW/TBW ratio (B 0.313, p 0.02) and waist circumference (B 0.304, p 0.016) were independent risk factors for LVH. We want to underline that, besides maintaining residual renal function, strict blood pressure control, particularly diastolic blood pressure, and avoiding hypervolemia and abdominal obesity should be main clinical goals in follow-up of PD patients in order to prevent LVH progression.

Are you bleeding? Validation of a machine-learning algorithm for determination of blood volume status: application to remote triage

Due to limited remote triage monitoring capabilities, combat medics cannot currently distinguish bleeding soldiers from those engaged in combat unless they have physical access to them. The purpose of this study was to test the hypothesis that low-level physiological signals can be used to develop a machine-learning algorithm for tracking changes in central blood volume that will subsequently distinguish central hypovolemia from physical activity. Twenty-four subjects underwent central hypovolemia via lower body negative pressure (LBNP), and a supine-cycle exercise protocol. Exercise workloads were determined by matching heart rate responses from each LBNP level. Heart rate and stroke volume (SV) were measured via Finometer. ECG, heat flux, skin temperature, galvanic skin response, and two-axis acceleration were obtained from an armband (SenseWear Pro2) and used to develop a machine-learning algorithm to predict changes in SV as an index of central blood volume under both conditions. The algorithm SV was retrospectively compared against Finometer SV. A model was developed to determine whether unknown data points could be correctly classified into these two conditions using leave-one-out cross-validation. Algorithm vs. Finometer SV values were strongly correlated for LBNP in individual subjects (mean r = 0.92; range 0.75-0.98), but only moderately correlated for exercise (mean r = 0.50; range -0.23-0.87). From the first level of LBNP/exercise, the machine-learning algorithm was able to distinguish between LBNP and exercise with high accuracy, sensitivity, and specificity (all ≥90%). In conclusion, a machine-learning algorithm developed from low-level physiological signals could reliably distinguish central hypovolemia from exercise, indicating that this device could provide battlefield remote triage capabilities.

432

Introduction: Cerebral salt wasting (CSW) and the syndrome of inappropriate antidiuretic hormone release (SIADH) are two causes of hyponatremia in neurocritical care patients. CSW presents with decreased plasma volume (PV); SIADH presents with normal or increased PV. Clinical exam and CVP are unreliable for assessing circulating volume. Bedside isotopic blood volume analysis (BVA) can accurately measure PV and total blood volume (TBV). CSW and SIADH are the result of alterations in the hormonal regulation of plasma volume. Therefore plasma volume levels can be used to distinguish between CSW and SIADH. Methods: The records of patients admitted between 2007 and 2013 who underwent a BVA were reviewed. Patients with a neurointensive care diagnosis were grouped by BVA and Na+ levels. Data collected included: Age, Ht, Wt, Sex; Serum Na+, K+, BUN, Crt, Hct; Urine SG, Na+, Osmo. Additionally, BVA results & outcome were recorded. The incidence of CSW and SIADH based on BVA was determined. A normalized Hct was calculated based on the actual red cell volume and predicted normal plasma volume based on the BVA results. Results: The records of 95 patients with a neurointensive care diagnosis were reviewed. There were a total of 106 BVA performed on these 95 patients. The group consisted of 50 females and 45 males. The mean age was 59.8 + 18.5 years. Overall mortality was 22.1% (21/95). 53.7% (51/95) of patients experienced hyponatremic episodes (Serum Na+< 136 mEq/dl). The most common neurological diagnoses were intraparenchymal hemorrhage (IPH) (26.5%), subarachnoid hemorrhage (SAH) (26.5%), or subdural hematoma (SDH) (24.5%). BVA results in the hyponatremic group demonstrated that plasma volume (PV) was Decreased in 7.8% (4/51), Normal in 43.1% (22/51) and Increased in 49.0% (25/51). Regardless of volume status, all patients had normocytic anemia. Peripheral Hct was 33.0 (+ 4.6), 29.8 (+ 4.5), and 29.0 (+ 4.5) in the Decreased, Normal and Increased plasma volume patients, which was not significant. However, after correcting for plasma volume, the normalized Hct was 24.8 (+ 4.7), 25.5 (+ 5.5), and 30.4 (+ 6.6) in the Decreased, Normal and Increased plasma volume patients (p<0.05). No patient had increased Red Cell Volume (RCV), 3 had a normal RCV (5.9%). There was no significant difference in Hct based on the reason for neurocritical care. Total blood volume (TBV) was decreased in 45.1% (23/51), normal in 39.2% (20/51), and increased in 15.7% (8/51) of the patients. Serum Na+, K+, BUN, Crt, Hct and Urine SG, Na+, Osmolality were not associated with plasma or blood volume status. Among hyponatremic patients, mortality was 18.4%. Conclusions: Evaluation and treatment of hyponatremia in neurointensive care patients remains a challenge. Anemia is common in hyponatremic patients with neurocritical illness. Paradoxically, the normalized Hct is lowest in patients with decreased volume status. Peripheral Hct does not correlate with volume status and may be misleading in this group of patients. The mechanism for this anemia requires additional research. Based on plasma volume levels, CSW was present in only 7.8% of hyponatremic pts. SIADH appears to be more common than CSW in hyponatremic patients. Traditional markers of volume status are not useful in these pts. Measurement of TBV alone may incorrectly identify CSW in 45.1% of hyponatremic pts. Management of hyponatremia can be improved with BVA data and contraindicated interventions avoided. A prospective evaluation of BVA in neurointensive care patients is warranted.

Brain-type natriuretic peptide and right ventricular end-diastolic volume index measurements are imprecise estimates of circulating blood volume in critically ill subjects

Surrogate indicators have often been used to estimate intravascular volume to guide fluid management. Brain-type natriuretic peptide (BNP) has been used as a noninvasive adjunct in the diagnosis of fluid overload and as a marker of response to therapy, especially in individuals with congestive heart failure. Similarly, right ventricular end-diastolic volume index (RVEDVI) measurements represent another parameter used to guide fluid resuscitation. The aim of this study was to evaluate whether BNP and RVEDVI are clinically valuable parameters that can distinguish among hypovolemia, euvolemia, and hypervolemia, as measured by blood volume (BV) analysis in critically ill surgical subjects. This observational study was part of a prospective, randomized controlled trial. Subjects with pulmonary artery catheters for the treatment of traumatic injuries, severe sepsis/septic shock, cardiovascular collapse, adult respiratory distress syndrome, and postsurgical care were studied. Circulating BV was measured by a radioisotope dilution technique using the BVA-100 Analyzer (Daxor Corporation, New York, NY) within the first 24 hours of acute resuscitation. BV results were reported as percent deviation from the patient's ideal BV based on height and percent deviation from optimum weight. Hypovolemia was defined as less than 0%, euvolemia was defined as 0% to +16%, and hypervolemia was defined as greater than +16% deviation from ideal BV. RVEDVI was measured by continuous cardiac output pulmonary artery catheters (Edwards Lifesciences, Irvine, CA). BNP and RVEDVI measurements obtained with BV analysis were evaluated with Fisher's exact test and regression analysis. In 81 subjects, there was no difference in BV status between those with BNP of 500 pg/mL or greater and BNP of less than 500 pg/mL (p = 0.82) or in those with RVEDVI of 140 mL/m or greater and RVEDVI of less than 140 mL/m (p = 0.43). No linear relationship existed between BV and these parameters. In critically ill surgical patients, BNP and RVEDVI were not associated with intravascular volume status, although they may be useful as indices that reflect increased cardiac preload. Diagnostic study, level III.

Promoting early diagnosis of hemodynamic instability during simulated hemorrhage with the use of a real-time decision-assist algorithm

This study aimed to test the hypothesis that the addition of a real-time decision-assist machine learning algorithm by emergency medical system personnel could shorten the time needed to identify an unstable patient during a hemorrhage profile as compared with vital sign information alone. Fifty emergency medical team-paramedics from a large, urban fire department participated as subjects. Subjects viewed a monitor screen on two occasions as follows: (1) display of standard vital signs alone and (2) with the addition of an index (Compensatory Reserve Index) associated with estimated central blood volume status. The subjects were asked to push a computer key at any point in the sequence they believed the patient had become unstable based on information provided by the monitor screen. The average difference in time to identify hemodynamic instability between experimental and control groups was assessed by paired, two-tailed t test and reported with 95% confidence intervals (95% CI). The mean (SD) amount of time required to identify an unstable patient was 18.3 (4.1) minutes (95% CI, 17.2-19.4 minutes) without the algorithm and 10.7 (4.2) minutes (95% CI, 9.5-11.9 minutes) with the algorithm (p < 0.001). In a simulated patient encounter involving uncontrolled hemorrhage, the use of a monitor that estimates central blood volume loss was associated with early identification of impending hemodynamic instability. Physiologic monitors capable of early identification and estimation of the physiologic capacity to compensate for blood loss during hemorrhage may enable optimal guidance for hypotensive resuscitation. They may also help identify casualties benefitting from forward administration of plasma, antifibrinolytics and procoagulants in a remote damage-control resuscitation model.

The Capability of Skin Conductance to Monitor Pain Compared to Other Physiological Pain Assessment Tools in Children and Neonates

Background: In some European countries and the US it is mandatory to assess and treat pain. In Pubmed there are more than 240 papers when searching for “skin conductance” and “pain”. Aims: The aim is to review the utility of the skin conductance responses (SCR)/sec to assess pain in infants and children. Study design: Two searches in Pubmed, where one includes the key words “skin conductance”, “pain”, and “children”. Search two included “skin conductance”, “pain”, and “infants”. The finds in these searches are discussed and compared with other physiological pain assessment tools. Outcome measures: Search one; regarding children, included twelve papers, and search two, regarding infants, included 20 papers. Results: All the found papers show that the SCR/sec increases during defined painful procedures. Postoperatively, at intensive care units, and at neonatal units, the SCR/sec shows high sensitivity to monitor pain, but a lower specificity. The the SCR/sec is the most accurate means to assess pain when compared to the HR and peripheral oxygen saturation. HR is influenced from respiratory rhythm, changes in blood volume status, drugs acting on the blood circulation, environmental temperature, and emotional stress, and is therefore less specific to pain than the SCR/sec which only is influenced from emotional stress. For infants and children, variation for SCR/sec is low compared to HR and peripheral oxygen saturation when the patients are at the same pain/discomfort level. Conclusions: The SCR/sec could be adjunctive warning tool for when to validate possible pain.

Fluid resuscitation strategy in septic shock following urinary infection with severe pulmonary capillary leakage

To characterize septic shock following urinary infection with severe pulmonary capillary leakage, and to evaluate the fluid therapy on treatment of hypovolemic shock and the role of transpulmonary thermodilution technique with pulse induced continuous cardiac output (PiCCO) monitoring. A retrospective study was conducted. Eight patients surviving septic shock following urinary infection with severe pulmonary capillary leakage were enrolled, and all of them underwent PiCCO monitoring in the intensive care unit (ICU) when the diagnosis was established. The monitoring started at admission, and ended when shock was corrected or transferred from ICU. The clinical data including general end diastolic volume index (GEDVI), extravascular lung water index (EVLWI), input and output volume of fluid, net fluid balance, oxygenation index (PaO2/FiO2), the level of arterial blood lactic acid, and chest X ray were collected and analyzed retrospectively the characteristics of septic shock following urinary infection, and the role of PiCCO monitoring in fluid resuscitation. Septic shock following urinary infection occurred in a median of 4.5 days in 8 patients after renal and ureteric calculi lithotripsy, accompanied with severe pulmonary vessel effusion and hypoxemia in different degrees. The mean value of EVLWI was (22±7) ml/kg, and the PaO2/FiO2 (164±82) mm Hg at the time of admission to ICU. Conservative fluid resuscitation strategy was adopted in management of septic shock with severe pulmonary capillary leakage, the mean fluid input in 8 patients was (2412±1121) ml/d, and the net fluid balance -553 ml/d, and the central venous pressure (CVP) and GEDVI were maintained at levels of (9±3) mm Hg and (749±236) ml/m(2) respectively. Diuretics were administered to 6 patients and the mean dosage of fursemide was (264±133) mg. Norepinephrine and dobutamine infusion were given to 7 patients to maintain blood pressure at normal range for (4±1) days. Seven patients were mechanically ventilated, and the mean length of ventilation was (8±6) days. All of the 8 patients survived from septic shock after fluid resuscitation therapy, with the mean level of EVLWI decreased gradually to (11±3) ml/kg, and the lung effusion was absorbed significantly as shown in chest X ray. The mean length of ICU stay was (17±11) days. Pearson correlate analysis showed EVLWI was significantly correlated with PaO(2)/FiO(2) and the levels of artery blood serum lactate, with r -0.91 and 0.70 respectively (both P<0.05). Successful management of septic shock following urinary infection with severe pulmonary vascular leakage is based on accurate assessment of blood volume status, especially the degree of EVLWI, emphasis on prevention of EVLWI increase, and adoption of conservative fluid resuscitation strategies according to hemodynamic monitoring parameters. PiCCO monitoring is a useful tool in assessment of the blood volume status and management of fluid resuscitation in patients with urinary lithotripsy-associated septic shock complicated with severe pulmonary edema.

14 Prediction of Fluid Responsiveness in Mechanically Ventilated Children Using Transoesophageal Doppler (TOD) and Transthoracic Echocardiography (TTE) in Algerian’s Picu

Background and aimsCirculatory failure treatment needs to assess blood volume status, in order to detect a hypovolemia requiring blood volume expansion. In this way, new dynamic echocardiographic and TOD parameters...

O-23 PREGNANT WOMAN WITH RH(D) ALLOIMMUNIZATION TREATED BY DOUBLE FILTRATE PLASMAPHERESIS AND INTRAVENOUS IMMUNOGLOBULIN

function was deranged in 3 of the five patients with one patient having a complete renal shut down. All patients had some degree of coagulopathy as per laboratory parameters but none had clinical signs/symptoms of coagulopathy. In view of the coagulopathy fresh frozen plasma (FFP) was used as replacement fluid. The blood volume status of 3 patients was normal but 2 patients had some degree of volume overload as per central venous pressure and X-ray findings. In these patients we restricted the replacement plasma to 80% in consultation with a nephrologist. Maintaining plasma ionized Calcium (Ca++) was a challenge and after a few very low Ca++ reading we resorted to initial Ca++ estimation and a loading dose of Ca chloride followed by hourly estimations and repeat doses as required. Discussion/Conclusion: In view of our institute being a tertiary care referral institute, we have a number of critically ill patients coming for treatment. We have developed protocols in the Transfusion Medicine Department to ensure optimum support for these patients during therapeutic apheresis. The important issues in the protocol are as followsAll procedures are done in the Intensive Care Unit with continuous monitoring and support of critical care staff. Nephrology consultation regarding fluid replacement is done in all cases with renal dysfunction. We have a stringent Ca++ estimation protocol which includes initial estimation followed by hourly repeat estimation.

2 Differential diagnosis of hyponatraemia

The appropriate management of hyponatraemia is reliant on the accurate identification of the underlying cause of the hyponatraemia. In the light of evidence which has shown that the use of a clinical algorithm appears to improve accuracy in the differential diagnosis of hyponatraemia, the European Hyponatraemia Network considered the use of two algorithms. One was developed from a nephrologist's view of hyponatraemia, while the other reflected the approach of an endocrinologist. Both of these algorithms concurred on the importance of assessing effective blood volume status and the measurement of urine sodium concentration in the diagnostic process. To demonstrate the importance of accurate diagnosis to the correct treatment of hyponatraemia, special consideration was given to hyponatraemia in neurosurgical patients. The differentiation between the syndrome of inappropriate antidiuretic hormone secretion (SIADH), acute adrenocorticotropic hormone (ACTH) deficiency, fluid overload and cerebral salt-wasting syndrome was discussed. In patients with SIADH, fluid restriction has been the mainstay of treatment despite the absence of an evidence base for its use. An approach to using fluid restriction to raise serum tonicity in patients with SIADH and to identify patients who are likely to be recalcitrant to fluid restriction was also suggested.

Hämodynamisches Monitoring - Verbessertes Outcome durch erweitertes perioperatives hämodynamisches Monitoring

Advanced haemodynamic monitoring provides information on blood flow, volume status, and oxygen supply to demand ratio. Together with related therapeutic algorithms these variables can be used to optimize cardiac preload and oxygen delivery in the perioperative period. There is increasing evidence that a goal-directed therapy can improve perioperative outcome. In this review we will briefly describe different target variables and their relevance for the haemodynamic optimization of high-risk surgical patients.

The Treatment Strategy in A Case of Concomitant Left Renal Cell Carcinoma and Left Atrial Myxoma

This case report describes the treatment plan of a patient with concomitant left renal cell carcinoma and incidentally discovered left atrial myxoma. Myxomas are cardiac benign tumors, mainly located in left atrium. Clinical symptoms or complications are embolic related events or valvular dysfunction, c ausing even cardiac arrest. In such a pathologic situation the treatment strategy includes: correct identification of all the possible problems (diagnoses) and the plan of surgical priorities. Careful examination, shorter cardiopulmonary bypass period , good blood pressure and volume status, and perioperative renal protection can guarantee good outcome of the patient. doi:10.4021/jmc83w

How does late nephrological co-management impact chronic kidney disease? - An observational study

To assess the impact of late referral (LR) for nephrological co-management compared with early referral (ER) on morbidity and mortality in chronic kidney disease (CKD) and to identify individual factors associated with higher mortality in LR, correcting for lead-time and immortal time bias. Retrospective observational study comparing 46 LR patients with 103 ER patients. The quality of CKD management was assessed by measures to prevent CKD progression and to modify CKD complications and cardiovascular risk factors according to current guidelines. One-year mortality of LR and ER was compared and factors associated with mortality were identified. Analysis was performed with equivalent GFR (glomerular filtration rate) of ER and LR at baseline to correct for lead-time and immortal time bias. Late referral was associated with inferior control of most risk factors for CKD progression, CKD complications and cardiovascular risk factors. In particular, glycaemic control, the use of angiotensin converting enzyme inhibitors and angiotensin-2-receptor blockers in diabetic nephropathy or proteinuria, the control of nutritional and volume status were inferior in LR. One-year mortality was significantly higher in LR (RR 5.9 (95% CI 1.5-19.6); p < 0.01). Inadequate control of blood pressure, anaemia, volume status, malnutrition and emergency initial dialysis, but not LR itself were independently associated with mortality. Late referral was associated with a substantially lower survival after correction for lead-time and immortal time bias and with inferior control of most risk factors for CKD progression, complications and cardiovascular risk factors. CKD patients may particularly profit from adequate control of blood pressure, anaemia, nutritional and volume status, and avoidance of emergency initial dialysis as these factors may predominately contribute to survival.

A “fussy eater” with renal failure

In May, 2009, a 17-year-old girl was admitted with a 10-day history of anorexia and vomiting. She had no significant medical or family history, and was on no medication other than the oral contraceptive pill. Examination was unremarkable, with normal blood pressure and volume status. She had severe non-oliguric renal impairment (urea 64 mmol/L, creatinine 1596 μmol/L). Urinalysis showed haematuria and proteinuria. Full blood count showed macrocytic anaemia (haemoglobin 88 g/L, MCV 116 fL); blood film showed hypersegmented neutrophils.

The Treatment Strategy in A Case of Concomitant Left Renal Cell Carcinoma and Left Atrial Myxoma

This case report describes the treatment plan of a patient with concomitant left renal cell carcinoma and incidentally discovered left atrial myxoma. Myxomas are cardiac benign tumors, mainly located in left atrium. Clinical symptoms or complications are embolic related events or valvular dysfunction, causing even cardiac arrest. In such a pathologic situation the treatment strategy includes: correct identification of all the possible problems (diagnoses) and the plan of surgical priorities. Careful examination, shorter cardiopulmonary bypass period, good blood pressure and volume status, and perioperative renal protection can guarantee good outcome of the patient. J Med Cases. 2010;1(3):114-117 doi: https://doi.org/10.4021/jmc83w

Changes in hepatic blood flow during whole body hyperthermia

Purpose: Changes in blood flow distribution are important for heat dispersion and for supportive therapeutic strategies such as simultaneous whole body hyperthermia (WBH) and administration of chemotherapy. The aim of this clinical study was to determine changes in hepatic blood flow during WBH for the treatment of metastatic cancer.Materials and methods: This observational clinical study was part of a phase I/II feasibility study of WBH. WBH was induced using a radiant heat device. Hepatic blood flow was estimated using indocyanine green clearance measurements. The plasma disappearance rate of indocyanine green (PDR-ICG) was recorded in percent/min. We used an invasive thermo-dye-dilution technique to estimate hepatic blood flow, cardiac output, and volume status. Mean arterial blood pressure was also measured invasively. To determine the effects of hyperthermia the measurements were performed at defined temperature points.Results: In 10 of 22 treatments the PDR-ICG fell below normal values during hyperthermia, which represented a significant fall in hepatic blood flow. Cardiac output, volume status, and mean arterial blood pressure did not differ between patients whose liver blood flow was reduced and those whose liver blood flow remained unchanged.Conclusions: We observed distinct reductions in hepatic blood flow during WBH, which suggested a significant redistribution of blood flow away from the core during WBH. This was not mirrored by global circulatory parameters.

Apolipoprotein A-I mimetic peptide treatment inhibits inflammatory responses and improves survival in septic rats

Systemic inflammation induces a multiple organ dysfunction syndrome that contributes to morbidity and mortality in septic patients. Since increasing plasma apolipoprotein A-I (apoA-I) and HDL may reduce the complications of sepsis, we tested the hypothesis that the apoA-I mimetic peptide 4F confers similar protective effects in rats undergoing cecal ligation and puncture (CLP) injury. Male Sprague-Dawley rats were randomized to undergo CLP or sham surgery. IL-6 levels were significantly elevated in plasma by 6 h after CLP surgery compared with shams. In subsequent studies, CLP rats were further subdivided to receive vehicle or 4F (10 mg/kg) by intraperitoneal injection, 6 h after sepsis induction. Sham-operated rats received saline. Echocardiographic studies showed a reduction in left ventricular end-diastolic volume, stroke volume, and cardiac output (CO) 24 h after CLP surgery. These changes were associated with reduced blood volume and left ventricular filling pressure. 4F treatment improved blood volume status, increased CO, and reduced plasma IL-6 in CLP rats. Total cholesterol (TC) and HDL were 79 +/- 5 and 61 +/- 4 mg/dl, respectively, in sham rats. TC was significantly reduced in CLP rats (54 +/- 3 mg/dl) due to a reduction in HDL (26 +/- 3 mg/dl). 4F administration to CLP rats attenuated the reduction in TC (69 +/- 4 mg/dl) and HDL (41 +/- 3 mg/dl) and prevented sepsis-induced changes in HDL protein composition. Increased plasma HDL in 4F-treated CLP rats was associated with an improvement in CO and reduced mortality. It is proposed that protective effects of 4F are related to its ability to prevent the sepsis-induced reduction in plasma HDL.

The effects of low-sodium peritoneal dialysis fluids on blood pressure, thirst and volume status

Background. Poor ultrafiltration is associated with worse outcomes in peritoneal dialysis (PD) patients. This might in part reflect problems associated with salt and water excess. Increasing the diffusive component of peritoneal sodium removal using low-sodium PD fluids might have beneficial effects on blood pressure (BP), thirst and fluid status that could translate into clinical benefits.Methods. Using a multicentre, prospective, baseline controlled (1 month), non-randomized intervention (2 months) design, two novel solutions designed from predictions using the three-pore model were investigated. In group A ([Na+] = 115 mmol/l), the glucose (G) was increased to 2.0% to compensate for reduced osmolality whereas in group B ([Na+] = 102 mmol/l), it was unchanged (2.5%). Both solutions were substituted for one 3- to 5-h exchange per day and no change was made to the rest of the dialysis regime.Results. Ten patients in group A and 15 in group B completed the study. Both solutions resulted in significant increases (30–50 mmol/dwell) in diffusive sodium removal during the test exchanges, P < 0.001. Ultrafiltration was maintained in group A but reduced in group B. Ambulatory nocturnal mean BP fell in group A [93.1 ± 10.6 mmHg (±SD) versus 85.1 ± 10.2 mmHg, P < 0.05], but was stable in group B (95.4 ± 9.4 versus 95.1.1 ± 10.7 mmHg, NS). Thirst reduced independent of appetite and mood in both groups by 2 months, more markedly in group A. Indices of fluid status, including TBW by bioimpedance and D dilution also improved in group A, P < 0.05, whereas weight increased in group B.Conclusions. Increasing the diffusive component of sodium removal whilst maintaining ultrafiltration is associated with improvements in BP, thirst and fluid status. The lack of effect seen with uncompensated low-sodium dialysate suggests that these benefits cannot be achieved by manipulation of dialysate sodium removal alone. These observations provide valuable information of the design of future randomized studies to establish the clinical role for low-sodium dialysis fluids.