Fluid Status In Patients Research Articles

Volume Status among Hyponatremic admitted Patients

Introduction: The kidneys play a vital role in the management of hyponatremic patients with fluid disturbances. This task becomes more challenging in presence of comorbidities like chronic kidney disease or congestive heart failure. Accurate assessment of volume status and urinary sodium excretion is essential part for the correct management.. Both impaired renal function and compromised left ventricular function complicate the accurate evaluation of a patient's fluid status. Method: This cross-sectional prospective study was conducted over 262 adult patients with hyponatremia at The Indus Hospital, Karachi from 2017 to 2020. The patient's volume status at the time of enrollment was categorized as normovolemic, hypovolemic, or hypervolemic based on clinical examination. Spot urine sodium, chloride, potassium, urine and serum osmolality, serum urea, and Random blood sugar were all done. Results: There was a total of 262 patients in which 123 (46.9%) were male and 139 (53.1%) were female. The mean age was 54.1 ± 16.4 years. The overall comorbid burden was high 227(86.64%), in which hypertension and CKD contributed more. Out of 262 patients, half of them suffered from hypovolemia 131(50%). Spot urine sodium (>20 meq) was found in 219(83.58/%) patients, in which predominant volume status was hypovolemia 104(47.5%). Moreover, among those who could not survive were 28 (10.7%), in which hypovolemia contributed more than other volume status 12(42.85%). Conclusion: Hypovolemia came out to be the predominant volume status among hyponatremic patients with high comorbid burden. Majority excreted more sodium in spot urine sample despite of hypovolemia in majority.

Cost-effectiveness of bioimpedance-guided fluid management in patients undergoing haemodialysis: the BISTRO RCT.

The BioImpedance Spectroscopy to maintain Renal Output randomised controlled trial investigated the effect of bioimpedance spectroscopy added to a standardised fluid management protocol on the risk of anuria and preservation of residual kidney function (primary trial outcomes) in incident haemodialysis patients. Despite the economic burden of kidney disease, the cost-effectiveness of using bioimpedance measurements to guide fluid management in haemodialysis is not known. To assess the cost-effectiveness of bioimpedance-guided fluid management against current fluid management without bioimpedance. Within-trial economic evaluation (cost-utility analysis) carried out alongside the open-label, multicentre BioImpedance Spectroscopy to maintain Renal Output randomised controlled trial. Thirty-four United Kingdom outpatient haemodialysis centres, both main and satellite units, and their associated inpatient hospitals. Four hundred and thirty-nine adult haemodialysis patients with > 500 ml urine/day or residual glomerular filtration rate > 3 ml/minute/1.73 m2. The study intervention was the incorporation of bioimpedance technology-derived information about body composition into the clinical assessment of fluid status in patients with residual kidney function undergoing haemodialysis. Bioimpedance measurements were used in conjunction with usual clinical judgement to set a target weight that would avoid excessive fluid depletion at the end of a dialysis session. The primary outcome measure of the BioImpedance Spectroscopy to maintain Renal Output economic evaluation was incremental cost per additional quality-adjusted life-year gained over 24 months following randomisation. In the main (base-case) analysis, this was calculated from the perspective of the National Health Service and Personal Social Services. Sensitivity analyses explored the impact of different scenarios, sources of resource use data and value sets. The bioimpedance-guided fluid management group was associated with £382 lower average cost per patient (95% CI -£3319 to £2556) and 0.043 more quality-adjusted life-years (95% CI -0.019 to 0.105) compared with the current fluid management group, with neither values being statistically significant. The probability of bioimpedance-guided fluid management being cost-effective was 76% and 83% at commonly cited willingness-to-pay threshold of £20,000 and £30,000 per quality-adjusted life-year gained, respectively. The results remained robust to a series of sensitivity analyses. The missing data level was high for some resource use categories collected through case report forms, due to COVID-19 disruptions and a significant dropout rate in the informing BioImpedance Spectroscopy to maintain Renal Output trial. Compared with current fluid management, bioimpedance-guided fluid management produced a marginal reduction in costs and a small improvement in quality-adjusted life-years. Results from both the base-case and sensitivity analyses suggested that use of bioimpedance is likely to be cost-effective. Future work exploring the association between primary outcomes and longer-term survival would be useful. Should an important link be established, and relevant evidence becomes available, it would be informative to determine whether and how this might affect longer-term costs and benefits associated with bioimpedance-guided fluid management. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number HTA 14/216/01 (NIHR136142).

Point-of-care ultrasound is a useful adjunct tool to a clinician's assessment in the evaluation of severe hyponatraemia.

Hyponatraemia is the most common electrolyte disorder in inpatients resulting mainly from an imbalance in water homeostasis. Intravascular fluid status assessment is pivotal but is often challenging given multimorbidity, polypharmacy and diuretics use. We evaluated the utility of point-of-care ultrasound (POCUS) as an adjunct tool to standard practice for fluid assessment in severe hyponatraemia patients. Patients presenting with severe hyponatremia (Serum Sodium [Na] < 120 mmol/L; Normal range: 135-145 mol/L), managed by standard care were included. Hyponatraemia biochemistry work-up and POCUS examination were undertaken. Both clinician and POCUS independently assigned one of the three fluid status groups of hypovolaemia, hypervolaemia or euvolaemia. The final diagnosis of three fluid status groups at admission was made at the time of discharge by retrospective case review. Clinician's (standard of care) and POCUS fluid assessments were compared to that of the final diagnosis at the time of discharge. n = 19 patients were included. Median Na on admission was 113 mmol/L (109-116), improved to 129 ± 3 mmol/L on discharge. POCUS showed the higher degree of agreement with the final diagnosis (84%; n = 16/19), followed by the clinician (63%; n = 12/19). A trend towards higher accuracy of POCUS compared to clinician assessment of fluid status was noted (84% vs. 63%, p = 0.1611). Biochemistry was unreliable in 58% (n = 11/19) likely due to renal failure, polypharmacy or diuretic use. Inappropriate emergency fluid management was undertaken in 37% (n = 7/19) of cases based on initial clinician assessment. Thirst symptom correlated to hypovolaemia in 80% (4/5) cases. As subjective clinical and biochemistry assessments of fluid status are often unreliable due to co-morbidities and concurrent use of medications, POCUS can be a rapid objective diagnostic tool to assess fluid status in patients with severe hyponatraemia, to guide accurate emergency fluid management.

Lung Ultrasound and Bioelectrical Impedance Analysis for Fluid Status Assessing Patients Undergoing Maintenance Hemodialysis.

Volume overload is a fatal complication for people undergoing hemodialysis. Therefore, regulating a patient's "dry weight" based on their fluid status is imperative. Clinical experiences are too subjective to accurately judge a patient's fluid status, but techniques have emerged for improved fluid control in the two decades. Specifically, lung ultrasonography (LUS) uses a unique aspect of ultrasound images, the B-lines, to evaluate extravascular lung water, which has increasingly attracted attention. However, the role of B-line quantification in predicting short-mid-term death and/or cardiovascular complications is unclear. Patients undergoing MHD at the hemodialysis center of Zhejiang Provincial People's Hospital from October 1, 2020, to February 28, 2021, were examined using LUS and a bioelectrical impedance analysis before and after dialysis, and related clinical data were collected. All patients were followed up for one year after the examination, and deaths and first cardiovascular events (e.g., stroke, myocardial infarction, and heart failure) during this period were recorded. 98 patients were enrolled and divided into three groups in relation to their mild (<16 B-lines), moderate (16-30 B-lines), or severe (>30 B-lines) hypervolemia, defined by the number of B-lines. The long-term survival rate was significantly lower in the severe group than in the mild and moderate groups. LUS and bioelectrical impedance-related parameters (e.g., extracellular water-to-water ratio) were closely related to cardiac ultrasound parameters (left ventricular ejection fraction) (P < 0.001). The optimal B-line cutoff value on LUS for predicting fluid overload (defined clinically) in patients on hemodialysis was 11.5 lines (AUC = 0.840, 95% confidence interval 0.735-0.945, P < 0.001), and the diagnostic sensitivity and specificity were both 76.5%. During the one-year follow-up period, ten deaths and six cardiovascular events occurred. The survival rate was significantly lower in the severe group than in the mild group (log-rank test χ2 = 10.050, P=0.002) but did not differ between the severe and moderate groups (χ2 = 2.629, P=0.105). LUS is a cheap, noninvasive, simple, and repeatable volume-monitoring method that can assist with individualized fluid volume management in patients undergoing MHD. LUS results may also help to predict the short-mid-term survival rate of patients to a certain extent.

Correlations between preoperative fluid status assessed by bioimpedance analysis and hypotension during anaesthesia induction.

Hypovolaemia is presumed to be a common risk factor of postinduction hypotension (PIH), despite worldwide improvement in preoperative volume optimization. Correct assessment of fluid status in patients undergoing general anaesthesia remains a major challenge for anaesthesiologists. Bioimpedance analysis (BIA) is a sensitive method that allows objective assessment of patient fluid status as it can detect subclinical changes. The study's main purpose was to determine the correlation between the preoperative BIA assessed fluid status and PIH. This was an observational single centre study that included patients undergoing elective surgery. We defined PIH as the blood pressure decrease occurring during the first 10 minutes after induction of anaesthesia and orotracheal intubation before surgical incision. We standardized BIA evaluation, patient pre anaesthetic and preoperative preparation, technique and monitoring of anaesthesia. Our study included 115 patients. The mean age of the population was 58.1 years and the median values for total and intracellular water were 35.1 L and 19.3 L, respectively. In the univariable and multivariable analysis, only total body and intracellular water were associated with different definitions of PIH. There was no correlation between any of the BIA-derived parameters of fluid status and the duration of PIH. Our study shows that in elective surgery, bioimpedance could detect subtle, subclinical fluid parameters that are associated with PIH.

Fluid homeostatic action of dapagliflozin in patients with chronic kidney disease: the DAPA-BODY Trial.

Sodium glucose cotransporter 2 (SGLT2) inhibitors have both glucose-lowering and diuretic effects. We recently reported that the SGLT2 inhibitor dapagliflozin exerts short-term fluid homeostatic action in patients with chronic kidney disease (CKD). However, the long-term effects of SGLT2 inhibitors on body fluid status in patients with CKD remain unclear. This was a prospective, non-randomized, open-label study that included a dapagliflozin treatment group (n = 73) and a control group (n = 24) who were followed for 6 months. Body fluid volume was measured using a bioimpedance analysis device. The extracellular water-to-total body water ratio (ECW/TBW), a predictor of renal outcomes, was used as a parameter for body fluid status (fluid retention, 0.400 ≤ ECW/TBW). Six-month treatment with dapagliflozin significantly decreased ECW/TBW compared with the control group (-0.65% ± 2.03% vs. 0.97% ± 2.49%, p = 0.0018). Furthermore, dapagliflozin decreased the ECW/TBW in patients with baseline fluid retention, but not in patients without baseline fluid retention (-1.47% ± 1.93% vs. -0.01% ± 1.88%, p = 0.0017). Vasopressin surrogate marker copeptin levels were similar between the control and dapagliflozin groups at 6 months (32.3 ± 33.4 vs. 30.6 ± 30.1 pmol/L, p = 0.8227). However, dapagliflozin significantly increased the change in copeptin levels at 1 week (39.0% ± 41.6%, p = 0.0010), suggesting a compensatory increase in vasopressin secretion to prevent hypovolemia. Renin and aldosterone levels were similar between the control and dapagliflozin groups at 6 months, while epinephrine and norepinephrine (markers of sympathetic nervous system activity) were significantly lower in the dapagliflozin group than in the control group. In conclusion, the SGLT2 inhibitor dapagliflozin ameliorated fluid retention and maintained euvolemic fluid status in patients with CKD, suggesting that SGLT2 inhibitors exert sustained fluid homeostatic actions in patients with various fluid backgrounds. Clinical trial registration: https://www.umin.ac.jp/ctr/, identifier [UMIN000048568].

Soluble Suppression of Tumorigenicity 2 (sST2) in Patients with Predominantly Decompensated Right Heart Failure—A Prospective Observational Study

Right heart failure is a major challenge in clinical practice. Soluble Suppression of Tumorigenicity-2 (sST2), a member of the interleukin-1-receptor family, may have clinical prognostic value. The aim of this study was to analyze whether sST2 correlates with signs of acute right heart decompensation. This prospective single-center study included 50 patients admitted for clinical signs of predominant right heart decompensation. Signs of reduced blood supply to other organs (e.g., renal function parameter, troponin T, NT-proBNP), diuretics, and signs of venous congestion (inferior vena cava (IVC) diameter) with fluid retention (weight gain, peripheral edema) resulting from reduced RV function were analyzed. The degree of peripheral edema was defined as none, mild (5–6 mm depressible, regression in 15–60 s) or severe (&gt;7 mm depressible, regression in 2–3 min). sST2 levels were measured at the day of hospitalization. A total of 78.7% showed severe peripheral edema. The median concentration of sST2 was 35.2 ng/mL (25.–75. percentiles 17.2–46.7). sST2 is correlated with the peripheral edema degree (rSpearman = 0.427, p = 0.004) and the diameter of IVC (r = 0.786, p = 0.036), while NT-proBNP (r = 0.114, p = 0.456), troponin T (r = 0.123, p = 0.430), creatinine-based eGFR (r = −0.207, p = 0.195), or cystatin C-based eGFR (r = −0.032, p = 0.839) did not. sST2, but no other established marker, is correlated with peripheral and central fluid status in patients with decompensated right heart failure.

Abstract 12380: Importance of Quantifying Lung Fluid Status in Patients With Heart Failure Using Chest Computed Tomography

Background: Heart failure (HF) is a complex condition that requires accurate assessment for optimal management. B-type natriuretic peptide (BNP) has been widely used for diagnosis and monitoring, but its correlation with symptoms and prognosis can be inconsistent. This study investigates the utility of chest computed tomography (CT)-based evaluation of lung congestion as an additional tool in HF. Methods: CT imaging (SOMATOM Force, Siemens Healthineers) was performed in 129 HF patients on admission. Concurrently, BNP levels were measured. For image analysis, mean lung density (MLD), an index of lung congestion obtained from imaging, was analyzed by image analysis software (Syngo. CT Pulmo 3D, Siemens Healthineers). MLD was converted to fluid content (FC) in percentage units according to the equation: FC [%] = (MLD + 1000) / 10. The correlation between CT findings, BNP levels, clinical data, and prognosis was analyzed. Results: The FC of HF patients were significantly higher than those of non-HF patients (30.2 ± 6.2% vs. 18.2 ± 4.1%, p &lt; 0.01), and showed a weak correlation with BNP levels at admission (r = 0.205, p = 0.020). The subjects were divided into four groups based on FC values (median 30.2%) and BNP levels (median 617 pg/mL): S1 (&lt;30.2, &lt;617), 2 (≥30.2, &lt;617), S3 (&lt;30.2, ≥617), and S4 (≥30.2, ≥617). During the observation period of 7 to 38 months (mean 19.5 months), 38 out of 129 patients died. FC values were significantly higher in patients who were readmitted (32.2 ± 6.2% vs. 29.4 ± 6.1%, p = 0.024). Cardiovascular death and survival were compared between groups (Figure). Group S1 showed significantly better survival compared to the other groups. Higher mortality rates were observed in groups with the higher FC values, even in those with lower BNP levels. Conclusion: The present data suggest that the evaluation of the lung congestion level (FC value) using CT imaging on admission in HF patients is an additional indicator for accurate prognostic evaluation, in addition to BNP.

The kinocardiograph for assessment of fluid status in patients with acute decompensated heart failure.

To improve telemonitoring strategies in heart failure patients, there is a need for novel non-obtrusive sensors that monitor parameters closely related to intracardiac filling pressures. This proof-of-concept study aims to evaluate the responsiveness of cardiac kinetic energy (KE) measured with the Kinocardiograph (KCG), consisting of a seismocardiographic (SCG) sensor and a ballistocardiographic (BCG) sensor, during treatment of patients with acute decompensated heart failure. Eleven patients with acute decompensated heart failure who were hospitalized for treatment with intravenous diuretics received daily KCG measurements. The KCG measurements were compared with the diameter of the inferior vena cava (IVC) and body weight. Follow-up stopped at discharge, that is, in the recompensated state. Median (interquartile range) weight and IVC diameter decreased significantly after diuretic treatment [weight 74.5 (67.6-98.7) to 73.3 (66.7-95.6) kg, P=0.003; IVC diameter 2.47 (2.33-2.99) to 1.78 (1.65-2.47) cm, P=0.03]. In contrast with BCG measurements, significant changes in median KE measured with SCG were observed during the passive filling phase of the diastole [SGG: 0.48 (0.39-0.60) to 0.69 (0.56-0.84), P=0.026; BCG: 0.68 (0.46-0.73) to 0.68 (0.59-0.82), P=0.062], the active filling phase of the diastole [SCG: 0.38 (0.30-0.61) to 0.31 (0.09-0.47), P=0.016; BCG: 0.29 (0.17-0.39) to 0.26 (0.20-0.34), P=0.248], and the ratio between the passive and active filling phases [SCG: 2.76 (1.68-5.30) to 5.02 (3.13-10.17), P=0.006; BCG: 5.87 (3.57-7.55) to 5.27 (3.95-9.43), P=0.790]. The correlations between changes in KE during the passive and active filling phases, using SCG, and changes in weight or IVC were non-significant. Systolic KE did not show significant changes. KE measured with the KCG using SCG is highly responsive to changes in fluid status. Future research is needed to confirm its accuracy in a larger study population and specifically its application for detection of clinical deterioration in the home-environment.

Understanding nursing perceptions of intravenous fluid management practices.

Intravenous (IV) fluids are routinely used in hospitalized patients. As IV fluids are an everyday occurrence, their importance is often overlooked. Many patients receive large volumes of fluid during resuscitation to aid in the promotion of tissue perfusion. Nurses regularly administer IV fluids as part of maintenance infusions or as life-saving therapies and, therefore, need to understand these fluids' impact on their patients. Understanding nurses' existing perceptions of IV fluid management practices are crucial to improving practice. This study used an online survey to gather information on nursing perceptions of IV fluids. Four hundred and sixty-two Canadian nurses from diverse backgrounds were surveyed, including registered nurses, licensed practical nurses and student nurses. The study found that the majority of participants agreed that IV fluids, including type, amount, and rationale for infusion, were important. They also agreed that fluids could impact patient outcomes. However, the study found that, despite recognizing the value and importance of fluid management, many nurses struggled with recognizing how to determine a patient's fluid status versus fluid responsiveness. This study supports improving nursing education to understand better the differences between fluid volume status and volume responsiveness. Our study also provides evidence that nurses need access to more sophisticated tools to conduct dynamic assessments and better meet patients' needs.

Evaluating the Effect of Nursing-Performed Point-of-Care Ultrasound on Septic Emergency Department Patients.

Introduction Nursing-performed point-of-care ultrasound (NP-POCUS) studies have been performed on applications such as ultrasound-guided peripheral intravenous line placement and assessing bladder volume. However, research on the use of NP-POCUS in the management of septic patients remains limited. The purpose of this quality improvement study was to investigate how NP-POCUS could impact fluid treatment decisions affecting septic patients in the emergency department (ED)using a focused IVC and lung ultrasound protocol. Methods Nurses received standardized training in POCUS and performed inferior vena cava (IVC) and lung ultrasound scans on septic patients in the ED at predetermined intervals (hours: zero, three, and six). Based on their findings, they were asked to make recommendations on fluid management. Emergency physicians (EPs), both residents and attendings, are providing recommendations for fluid management without the use of ultrasound, which is being compared to the nurse-driven POCUS assessment of fluid management. EPs reviewed the NP-POCUS assessments of patient fluid status to determine nursing accuracy. Results A total of 104 patients were scanned, with a mean age of 60.7 years. EPs agreed with nursing ultrasound assessments in 99.1% of cases. Nursing ultrasound images changed management or increased physician confidence in current treatment plans83.7% and 96.6% of the time, respectively. Before reviewing saved nursing ultrasound images, EPs underestimated fluid tolerance in 37.5% of cases, overestimated fluid tolerance in 26% of cases, and correctly estimated fluid tolerance (within 500 ml) in 36.5% of cases. Throughout resuscitation, IVCs became less collapsible, the number of cases with B-lines was essentially unchanged, and less fluid was recommended. Conclusion This study demonstrated that nurse-performed POCUS is feasible and may have a meaningful impact on how physicians manage septic patients in the emergency department.

#5448 INCIDENCE OF ACUTE PULMONARY EDEMA AFTER THE SYSTEMATIC USE OF ULTRASOUND B-LINES

Abstract Background and Aims Acute pulmonary edema (APE) due to fluid overload is considered the most feared complication in hemodialysis patients. Various diagnostic tests have been proposed to assess fluid status in patients with end stage kidney failure (ESKF) and among these lung ultrasound (by measuring the number of B-Lines) is emerging as a promising tool to identify pulmonary congestion in this patient-population. Method In the setting of a retrospective study, we pragmatically compared the incidence rate of APE in our center before and after the implementation of lung ultrasound as a routine practice in our unit. Two periods were considered. A pre-implementation period [from 01/01/2007 to 31/12/2008, total person-time: 1913 months/patient, n = 98 patients (Group 1), 85 prevalent and 13 incident patients] and a post-implementation period [from 01/01/2017 to 31/12/2018, total person-time: 2061 months/patient, n = 108 patients (Group 2), 81 prevalent and 27 incident patients]. By accurately reviewing the electronic medical records, all episodes of APE were counted, i.e. all episodes characterized by sudden or worsening dyspnea associated with signs of salt and water overload, confirmed by chest auscultation or chest X-Ray, which required an additional dialysis session and excluding events due to infectious or irritating problems. Results The two groups (Group 1 vs Group 2) were quite similar between them as for age (64±15 vs 67±14 years, p = 0.06), proportion of males (65% vs 62%, p = 0.37) and median dialysis vintage [40 months (interquartile Range, IQR: 16–93 months) vs 46 months (IQR: 12–92), p = 0.76]. The two groups did not differ as for diabetes (21% vs 25%, P = 0.33), hypertension (75% vs 71%, p = 0.36), and smoking habit (29% vs 28%, p = 0.51). Of note, the proportion of patients with background cardiovascular comorbidities was significantly higher in patients of Group 2 (enrolled in the post-implementation period) than in those of Group 1 (31% vs 19%, p = 0.04]. A total of 37 APE episodes in 18 patients (from 1 to 4 episodes per patient) were identified in patients of Group 1 vs 7 APE episodes in 5 patients (from 1 to 2 episodes per patient) in those of Group 2. The incidence rate of APE was 82% lower in patients during the post-implementation period (4 episodes per 100 patients/year, 95% CI: 1–8) than in those during the post implementation period (23 episodes per 100 patient/year, 95% CI: 17–32) (incidence rate ratio: 0.18, 95% CI: 0.10-0.29, p&amp;lt;0.001). Conclusion The systematic use of lung ultrasound (simple, easy to learn, rapid and non-invasive method, easily performed at the patient's bed) in every day clinical practice drastically reduced (-82%) the episodes of APE in hemodialysis patients. Further observational and interventional studies are needed to confirm these results.

The kinocardiograph for assessment of fluid status in patients with acute decompensated heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Aims To improve telemonitoring strategies in heart failure patients, there is a need for novel non-obtrusive sensors which monitor parameters closely related to intracardiac filling pressures. This proof-of-concept study aims to evaluate the responsiveness of cardiac kinetic energy (KE) measured with the Kinocardiograph (KCG), consisting of a seismocardiographic (SCG) sensor and a ballistocardiographic (BCG) sensor, during treatment of patients with acute decompensated heart failure (ADHF). Methods Eleven patients with ADHF who were hospitalized for treatment with intravenous diuretics, received daily KCG measurements. The KCG measurements were compared to the diameter of the inferior vena cava (IVC) and body weight. Follow-up stopped at discharge, i.e. in the recompensated state. Results Median (IQR) weight and IVC diameter decreased significantly after diuretic treatment (weight 74.5 (67.6–98.7) to 73.3 (66.7-95.6) kg, p=0.003; IVC diameter 2.47 (2.33–2.99) to 1.78 (1.65–2.47) cm, p=0.03). In contrast with BCG measurements, significant changes in median KE measured with SCG were observed during the passive filling phase of the diastole (0.48 (0.39–0.60) to 0.69 (0.56-0.84), p=0.026), the active filling phase of the diastole (0.38 (0.30–0.61) to 0.31 (0.09–0.47), p=0.016)) and the ratio between the passive and active filling phase (2.76 (1.68–5.30) to 5.02 (3.13–10.17), p=0.006). Systolic KE did not show significant changes. Conclusion KE measured with the KCG using SCG is highly responsive to changes in fluid status. Future research is needed to confirm its accuracy in a larger study population, and specifically its application for detection of clinical deterioration in the home-environment.

The Usefulness of Bioelectrical Impedance as a Marker of Fluid Status in Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis.

Bioelectrical impedanceanalysis (BIA) is a method that measures electrical currents conducted through water, which assesses fluid status by measuring extracellular water (ECW), total body water (TBW), and resistance (R). Limited studies are done to evaluate the utility of BIA in patients with congestive heart failure (CHF), and therefore, we performed a systematic review and meta-analysis to evaluate this.A comprehensive literature search was performed at Medline and Embase until March 2022. Our primary outcome was a comparison of TBW and ECW between patients with CHF and controls. Our secondary outcome was to compare R between the groups. All analysis was conducted using RevMan 5.4 software.Six studies with 1,046 patients met our inclusion criteria. Out of 1,046 patients, 526 had CHF and 538 had no CHF. Among patients with CHF, all 526 had decompensated CHF. There was no significant difference in TBW between patients with heart failure and the control group (mean deviation (MD) = 1.42 (-0.44-3.27), percent of variation (I2) = 0%,p = 0.13). ECW was significantly higher with an assessment of BIA in heart failure patients compared to patients in the control group (MD = 1.62 (0.82-2.42), I2 = 0%, p < 0.0001). Resistance of extracellular fluid was significantly lower in the heart failure group (MD = -45.64 (-72.88--18.41), I2 = 83%, p = 0.001). Publication bias was deferred as the number of included studies was less than 10. BIA can be helpful in ambulatory and inpatient setting to identify patients' fluid status, which can improve outcomes. However, larger prospective studies are needed to further evaluate the usefulness of BIA in the CHF population.

Validating a Simplified Lung Ultrasound Protocol for Detection and Quantification of Pulmonary Edema in Patients With Chronic Kidney Disease Receiving Maintenance Hemodialysis.

Pulmonary edema is a common clinical problem and lung ultrasound (LUS) presents an efficient method for evaluating this pathology. This study aims to investigate if a clinically efficient LUS protocol can quantify the level of extravascular lung fluid in patients receiving hemodialysis, and to develop a simplified B-line scoring system based on this protocol. A simple 8-area LUS approach was used for the assessment of the extravascular fluid status in patients before, during, and after receiving hemodialysis. The LUS assessments were compared to the amount of removed fluid over time. To determine the best B-line score system, different scorings for each zone were tested in a linear mixed model with pseudo R-square model fit against removed fluid. The B-line score was further validated through correlations with changes in oxygen saturation, grade of dyspnea, and body weight over time. A total of 53 patients were included and examined on 108 hemodialysis occasions. Median fluid removal was 2.3L. The B-line score model with best fit was a score of 0 points in a zone with 0 or 1 B-lines, 1 point with 2 or 3 B-lines, 2 points with 3 or more B-lines, and 3 points with any interstitial confluence. Using this B-line score, we found a significant association with amount of removed fluid, oxygen saturation, grade of dyspnea, and change in body weight. A straightforward protocol for LUS and B-line score system was shown valid for quantification of pulmonary edema and fluid removal in hemodialysis patients. The scoring system developed here can be useful also in other patient groups, but this requires further validation.

Bioimpedance-Guided Monitoring of Volume Status in Patients With Kidney Disease: A Systematic Review and Meta-Analysis.

Bioimpedance technologies are increasingly used to determine fluid status in patients with chronic kidney disease and those with end-stage kidney disease on dialysis. We aimed to determine whether this technology improves clinical outcomes as compared with usual care. We performed a systematic review and meta-analysis of trials, comparing fluid management guided by bioimpedance technologies to standard of care in patients with chronic kidney disease. Our primary outcome was all-cause mortality. Secondary outcomes included blood pressure control, all-cause hospitalization, major adverse cardiovascular events, and change in left ventricular mass index. Our search identified 819 citations of which 12 randomized controlled trials were included (2420 patients). No studies of non-dialysis-dependent chronic kidney disease patients met inclusion criteria. Mean age was 55 years and mean follow-up was 1 year. There was a statistically significant difference in all-cause mortality between both arms studied (risk ratio [RR] 0.64, 95% confidence interval [CI]: 0.44, 0.99). Better blood pressure control was observed in the bioimpedance arm of the included articles, weighted mean differences (WMD) -3.13 mm Hg (95% CI: -5.73, -0.53 mm Hg) for systolic blood pressure and WMD -2.50 mm Hg (95% CI: -4.36, -0.64 mm Hg) for diastolic blood pressure. No difference was observed concerning the other outcomes. Among patients on maintenance dialysis, bioimpedance-guided volume management showed decreased all-cause mortality and blood pressure but no significant difference in all-cause hospitalization, major adverse cardiac event, or change in left ventricular mass index. This may be due to a younger population sample than previous articles. Moreover, our study identified a knowledge gap by highlighting the lack of studies evaluating this technology in non-dialysis-dependent chronic kidney disease patients.

Fluid volume management in hemodialysis: never give up!

Every hemodialysis session starts with the question of how much fluid should be removed, which can currently not be answered precisely. Herein, we first revisit the "probing-dry-weight" concept, using the historical example of Tassin/France (practicing also "long, slow dialysis"): Mortality outcomes were, in the 1980s, better than registry data, but are nowadays similar to European average. In view of the negative primary end point in a recent trial on dry weight assessment, based on lung ultrasound-guided evaluation of fluid excess in the lungs, and a meta-analysis of prospective studies failing to show that bioimpedance-based interventions for correction of volume overload had a direct effect on all-cause mortality, we ask how to ever move forward. Clinical reasoning demands that as much information as possible should be gathered on the fluid status of patients undergoing dialysis. Besides body weight and blood pressure, measurements of bioimpedance and dialysate bolus-derived absolute blood volume can in principle be automatized, whereas lung ultrasound can be obtained routinely. In the era of machine learning, fluid management could consist of flexible target weight prescriptions, adjusted on a daily basis and accounting even for fluctuations in fluid-free body mass. In view of all the negative prospective results surrounding fluid management in hemodialysis, we propose this as a "never-give-up" approach.

Impact of fluid overload on blood pressure variability in patients on peritoneal dialysis

Fluid overload is a common complication in patients who are on continuous ambulatory peritoneal dialysis (CAPD). Blood pressure is the traditional indicator of fluid status in these patients. However, it has poor sensitivity. Blood pressure variability (BPV) can detect fluctuations in blood pressure sooner and more accurately and be useful for the assessment of fluid volume in hemodialysis patient. However, there are limited relevant studies involving patients on CAPD. This retrospective study included 175 patients on CAPD who underwent regular assessment of the peritoneal dialysis adequacy at 2–3-month intervals at our center from January 2018 to December 2020. The overhydration (OH) value was measured using a body composition monitor. Blood pressure measurements obtained in each visit over one-year follow-up were used to determine each patient’s BPV under peritoneal dialysis. The patients were divided into the normal volume (OH ≤2 L), mild volume overload (OH 2–4 L), and severe volume overload groups (OH ≥4 L). There was no significant between-group difference in the mean blood pressure (p > 0.05). However, the systolic and diastolic BPV values were significantly higher in the severe volume overload group than in the other groups (p < 0.05). Further correlation and regression analysis showed volume overload severity and BPV existed positive association, and BPV was also significantly associated with PD volume related indexes, including diabetes mellitus, blood parathyroid hormone levels, Kt/V and subjective global assessment scores in the volume overloaded group (p < 0.05). All these results suggested BPV may be a useful indicator for fluid status in PD patients.

SLICE: An algorithm for incorporating ultrasonography in the assessment of shocked or breathless patients.

SLICE is an algorithm for the integration of point-of-care ultrasound in the assessment and resuscitation of the shocked or breathless patient. It aims to determine the patient's fluid status, and identify reversible causes for the patient's clinical picture. SLICE stands for 'In a patient who is Shocked/Short of breath, scan the Lungs, IVC, Cardiac and Extra regions as indicated'. Its key advantages are that it explicitly guides resuscitative fluid management, can be performed rapidly and by clinicians with a broad range of sonographic experience, and can be used in a broad range of clinical scenarios. Its use has been successfully taught and implemented in routine clinical practice at our local institution.

Paediatric dengue shock syndrome and acute respiratory failure: a single-centre retrospective study

ObjectiveDengue shock syndrome (DSS) is a serious health condition leading to paediatric intensive care unit (PICU) admissions and deaths in tropical countries. Acute respiratory failure (ARF) is associated with DSS...