Signs Of Fluid Overload Research Articles

Myocardial performance improvement after iron replacement in heart failure patients with LVEF <50% and TSAT <20%: The IRON-PATH II echo-substudy

Abstract Background Iron deficiency (ID) is a prevalent comorbidity in patients with heart failure (HF) and left ventricular ejection fraction (LVEF) <50%. ID leads to impaired myocardial global function. Some echocardiographic parameters have demonstrated an additive value in advanced assessment of cardiac performance, like global longitudinal strain (GLS), myocardial work (MW) and its derivatives constructive work (CW), wasted work (WW) and work efficiency (WE). The usual definition of ID may have limitations in rightly identifying systemic iron status, especially those with isolated hypoferritinemia. However, the impact on cardiac function measured by echocardiography after intravenous iron replacement according to TSAT values has never been explored. Purpose Describe the myocardial performance associated with systemic ID defined as TSAT <20% in patients with HF compared to patients with HF without ID (TSAT ≥20%). Afterwards, we aimed to explore changes in myocardial function after iron replacement by echocardiography. Methods The IRON-PATH II was a multicenter, prospective, observational study. The total number of patients to be recruited was 210 in 7 centers across Spain and Portugal. Patients with HF and LVEF ≤50%, without signs of fluid overload or low cardiac output, and haemoglobin ≥11 g/dL were included. The IRON-PATH II echo-substudy included 100 patients who undergone a specific pilot evaluation of echocardiographic. All patients undergone an echocardiography at baseline, ID-patients received a second echocardiography three months after ID replenishment. Results The final study cohort included in the echo-substudy consisted of 98 patients, 41 (42%) were classified in the ID group (TSAT <20%). Regarding the usual definition of ID, 7 patients (15%) in the ID group had TSAT ≥20%, while 4 (7%) in the non-ID group showed TSAT <20%. Mean age was 72±10 years, 22 (22%) were women and most were in NYHA functional class II (71%). Ischemic was the main etiology of HF (50%). The ID group presented worse LV function expressed by LVEF (34% vs. 38%), WW (302[235.5-439,75] mmHg% vs. 209.5[136-297.25] mmHg%) and WE (74±10% vs. 80±10%) (Figure 1). Right ventricle function was also worse in the ID group when measured by fractional area change (FAC) (41.76[33.26-50.33] % vs 46.79[39.23 – 54.94] %) and RV coupling ratio (0.52±0.21 vs 0.64±0.24) but not by TAPSE. Strikingly, no differences were observed in any echocardiographic parameter of myocardial function between the non-ID patients compared with the ID-patients after iron replenishment (Table 1). Conclusions TSAT <20% identified ID status that causes impaired myocardial performance in HF patients. This can be reversed with intravenous iron repletion. This reversible damage to cardiac function can be detected by advanced echocardiographic parameters, both for LV (GLS, WE, MW, WW) and for RV (RVFW strain, RV coupling), but not by LVEF or TAPSE.Figure 1Table 1

Comparing the diagnostic considerations between general practitioners with a special interest in cardiovascular disease and those without in patients with symptoms suggestive of heart failure: a vignette study

BackgroundGeneral practitioners (GPs) specialized in cardiovascular disease (GPSI-CVD) may suspect heart failure (HF) more easily than GPs not specialized in CVD. We assessed whether GPSI-CVD consider investigations aimed at detecting HF more often than other GPs in two clinical scenarios of an older male person with respiratory and suggestive HF symptoms.MethodsIn this vignette study, Dutch GPs evaluated two vignettes. The first involved a 72-year-old man with hypertension and a 30 pack-year smoking history who presented himself with symptoms of a common cold, but also shortness of breath, reduced exercise tolerance, and signs of fluid overload. The second vignette was similar but now the 72-year-old man was known with chronic obstructive pulmonary disease (COPD).GPs could select diagnostic tests from a multiple-choice list with answer options targeted at HF, COPD or exacerbation of COPD, or lower respiratory tract infection. With Pearson Chi-square or Fisher’s exact test differences between the two GP groups were assessed regarding the chosen diagnostic tests.ResultsOf the 148 participating GPs, 25 were GPSI-CVD and 123 were other GPs. In the first vignette, GPSI-CVD more often considered performing electrocardiography (ECG) than other GPs (64.0% vs. 32.5%, p = 0.003). In the second vignette, GPSI-CVD were more inclined to perform both ECG (36.0% vs. 12.2%, p = 0.003) and natriuretic peptide testing (56.0% vs. 32.5%, p = 0.006).ConclusionsMost GPs seemed to consider multiple diagnoses, including HF, with GPSI-CVD more likely performing ECG and natriuretic peptide testing in an older male person with both respiratory and suggestive HF symptoms.

Symptoms and signs in patients with heart failure: association with 3-month hospitalisation and mortality

ObjectivesTo determine the association between symptoms and signs reported in primary care consultations following a new diagnosis of heart failure (HF), and 3-month hospitalisation and mortality.DesignNested case–control study with density-based...

Protocolised early de-resuscitation in septic shock (REDUCE): protocol for a randomised controlled multicentre feasibility trial

BackgroundFluid overload is associated with excess mortality in septic shock. Current approaches to reduce fluid overload include restrictive administration of fluid or active removal of accumulated fluid. However, evidence on...

Extracorporeal veno-venous ultrafiltration in congestive heart failure: What's the state of the art? A mini-review.

Hospitalizations for heart failure exceed 1 million per year in both the United States and Europe and more than 90% are due to symptoms and signs of fluid overload. Rates of rehospitalizations or emergency department visit at 60 days are remarkable regardless of whether loop diuretics were administered at low vs high doses or by bolus injection vs continuous infusion. Ultrafiltration (UF) has been considered a promising alternative to stepped diuretic therapy and it consists in the mechanical, adjustable removal of iso-tonic plasma water across a semipermeable membrane with the application of hydrostatic pressure gradient generated by a pump. Fluid removal with ultrafiltration presents several advantages such as elimination of higher amount of sodium with less neurohormonal activation. However, the conflicting results from UF studies highlight that patient selection and fluid removal targets are not completely understood. The best way to assess fluid status and therefore establish the fluid removal target is also still a matter of debate. Herein, we provide an up-to-date systematic review about the role of ultrafiltration among patients with fluid overload and its gaps in daily practice.

Central venous pressure and dynamic indices to assess fluid appropriateness in critically ill patients: A pilot study.

The correct identification of the appropriateness of fluid administration is important for the treatment of critically ill patients. Static and dynamic indices used to identify fluid responsiveness have been developed throughout the years, nonetheless fluid responsiveness does not indicate that fluid administration is appropriate, and indexes to evaluate appropriateness of fluid administration are lacking. The aim of this study was to evaluate if central venous pressure (CVP) anddynamic indices could correctly identify fluid appropriateness for critically ill patients. Data from 31 ICU patients, for a total of 53 observations, was included in the analysis. Patients were divided into two cohorts based on the appropriateness of fluid administration. Fluid appropriateness was defined in presence of a low cardiac index (< 2.5 l/min/m2) without any sign of fluid overload, as assessed by global end-diastolic volume index, extravascular lung water index or pulmonary artery occlusion pressure. For 10 patients, fluid administration was deemed appropriate, while for 21 patients it was deemed inappropriate. Central venous pressure was not different between the two cohorts (mean CVP 11 (4) mmHg in the fluid inappropriate group, 12 (4) mmHg in the fluid appropriate group, p 0.58). The same is true for pulse pressure variation (median PPV 5 [2, 9] % in the fluid inappropriate group, 4 [3, 13] % in the fluid appropriate group, p 0.57), for inferior vena cava distensibility (mean inferior vena cava distensibility 24 (14) % in the fluid inappropriate group, 22 (16) % in the fluid appropriate group, p 0.75) and for changes in end tidal carbon dioxide during a passive leg raising test (median d.ETCO2 1.5 [0.0, 2.0]% in the fluid inappropriate group, 1.0 [0.0, 2.0] % in the fluid appropriate group, p 0.98). There was no association between static and dynamic indices and fluid appropriateness. Central venous pressure, pulse pressure variation, changes in end tidal carbon dioxide during a passive leg raising test, inferior vena cava distensibility were not associated with fluid appropriateness in our cohorts.

Combination Diuretic Therapy to Counter Renal Sodium Avidity in Acute Heart Failure: Trials and Tribulations.

In contrast to significant advances in the management of patients with chronic heart failure over the past few years, there has been little change in how patients with acute heart failure are treated. Symptoms and signs of fluid overload are the primary reason for hospitalization of patients who experience acute decompensation of heart failure. Intravenous loop diuretics remain the mainstay of therapy in this patient population, with a significant subset of them showing suboptimal response to these agents leading to incomplete decongestion at the time of discharge. Combination diuretic therapy, that is, using loop diuretics along with an add-on agent, is a widely applied strategy to counter renal sodium avidity through sequential blockade of sodium absorption within renal tubules. The choice of the second diuretic is affected by several factors, including the site of action, the anticipated secondary effects, and the available evidence on their efficacy and safety. While the current guidelines recommend combination diuretic therapy as a viable option to overcome suboptimal response to loop diuretics, it is also acknowledged that this strategy is not supported by strong evidence and remains an area of uncertainty. The recent publication of landmark studies has regenerated the interest in sequential nephron blockade. In this article, we provide an overview of the results of the key studies on combination diuretic therapy in the setting of acute heart failure and discuss their findings primarily with regard to the effect on renal sodium avidity and cardiorenal outcomes.

Treatment Dilemma in an Unusual Case of Dengue Fever with Cardiomyopathy and Nephropathy: A Case Report

Dengue is a viral illness in humans caused by the bite of infected Aedes mosquitoes, mostly Aedes aegypti and also Aedes albopictus. There are four serotypes of the Dengue virus that cause infection in humans and may lead to a variety of complications. Myocarditis and cardiomyopathy can occur in several viral and non viral infections, increasing morbidity and mortality. Nephropathy may also arise in dengue fever, causing complications. The case presented here involved both complications, nephropathy and cardiomyopathy, posing treatment challenges in terms of altering fluid and electrolyte status, which hindered fluid therapy as fluid overload would be detrimental. However, the complications were reversible with the normalisation of echocardiography and urea and creatinine levels. Long-term follow-up is necessary to monitor cardiac and renal function, as some patients may progress to Chronic Kidney Disease (CKD). The patient presented with fever, headache, vomiting, and haematuria, along with signs of fluid overload. There was a past history of fever, and since both Immunoglobulin G (IgG) and IgM Dengue antibodies were positive, this may be a case of a second episode of dengue fever causing complications. This case report emphasises the diagnostic and treatment challenges in a dengue patient with cardiomyopathy and nephropathy, where excessive fluid replacement may increase morbidity and mortality. Additionally, long-term follow-up of these patients is necessary.

Fluid Resuscitation and Inotropic Support in Patients With Septic Shock Treated in Pediatric Emergency Department: An Open-Label Trial.

IntroductionFluid resuscitation and inotropic support are essential interventions to improve cardiovascular function in patients with septic shock. However, the optimal volume of fluids and the timing of inotropic support to achieve the resolution of shock are controversial. They may depend on the availability of critical care support services. AimsTo compare early versus the delayed start of epinephrine administration after fluids bolus in children with septic shock. Methods We conducted an open-label randomized trial in which patients under 18 years of age diagnosed with septic shock and arterial hypotension were treated in two Pediatric Emergency Departments in Paraguay (Hospital de Clinicas of Universidad Nacional de Asunción and Instituto Privado del Niño) between 2015 and 2020. Septic shock was defined according to the American College of Critical Care Medicine (ACCM) guidelines. All patients received antibiotics and 40 ml/kg of fluids (two boluses of 20ml/kg if there were no signs of fluid overload) during the first hour. They were then divided into two groups: Group 1 received epinephrine infusion and maintenance fluids. Group 2 received an additional 20 ml/kg of fluids and then was started on epinephrine infusion. ResultsOf 229 patients screened, 63 patients were included in the study. The mean age was 2.8±3.5 years. A total of 52% were female. Group 1 comprised 33 patients, and group 2 comprised a total of 30. Significant differences were found between group 1 and group 2 in the following: mortality (10% vs. 33%, p: 0.026, RR: 3.1, CI: 95%: 1-10), need for mechanical ventilation (10% vs. 41%, p: 0.006, RR: 4, CI: 95%: 1.3-12), and altered vascular hypoperfusion after one hour of interventions (7% vs. 59%, p<0,001, RR: 8.2, CI: 95%: 2-32).ConclusionsEarly administration of epinephrine infusion after initial fluid therapy was associated with better clinical outcomes than delayed administration.

Biochemical Efficacy of Sodium-Glucose Cotransporter 2 Inhibitors by Cardiovascular Risk Profile and Volume Status in a Real-World Diabetic Population.

Despite large-scale randomized clinical trials (RCTs) highlighting a consistent prognostic benefit of sodium-glucose cotransporter 2 inhibitors (SGLT2is) both in diabetic patients at high cardiovascular risk and in those with heart failure, there is relative paucity of data on their biochemical effects in a real-world setting. We performed a retrospective analysis on consecutive diabetic patients who were prescribed a SGLT2i in a tertiary referral center and completed at least 1 year of treatment. Changes in glycated hemoglobin, weight, and hematocrit were compared across 2 cardiovascular risk categories, defined through the inclusion criteria of 3 large RCTs. Of the 459 patients screened, 312 completed 1 year of treatment (68.0%), 92 interrupted the treatment prematurely (20.0%), and 55 were lost to follow-up (12.0%). The most common cause of drug discontinuation was genital or urinary tract infections (9.4%). At 1 year, reduction in glycated hemoglobin concentration (-0.7 ± 1.5%, P < 0.001) and body weight (2.4 ± 4.6 kg, P < 0.001) was comparable between patients at high versus low cardiovascular risk, while hematocrit increase (2.3 ± 3.3%, P < 0.001) was more marked in patients with high cardiovascular risk and low baseline hematocrit. In a real-world population of diabetic patients, SGLT2is were well-tolerated at 1 year and led to improved glycemic control and weight loss. Hematocrit increase was more consistent in patients with high cardiovascular risk and signs of fluid overload, indicating euvolemic restoration as a potential cardioprotective mechanism mediated by these compounds.

MO1045: Incidental Finding of Dextrocardia with Situs Inversus and the Absent Left Kidney in a 55-Year-Old Nepali Woman: A Case Report

Abstract BACKGROUND AND AIMS Dextrocardia is an abnormal congenital positioning of the heart: instead of the heart forming in the foetus on the left side, it flips over and forms on the right side. Situs inversus is a congenital condition in which the main visceral organs are reversed or mirrored from their usual positions. If both conditions are present, it is called situs inversus totalis. The prevalence of situs inversus is about 0.01%. It is generally an autosomal recessive genetic condition, although it can be X-linked. 25% of people with this condition have an underlying primary ciliary dyskinesia. We are reporting a case of a 55-year-old woman who was found to have a situs inversus totalis with an absent left kidney. No case report has been published yet. METHOD 54-year-old G5P4(2213) woman, government worker presented to an outpatient clinic with complaints of dysuria, frequency, hesitancy, suprapubic burning sensation and mild chest pain in January 2016. The patient did not have any cardiopulmonary symptoms like chronic coughs, nasal congestion and palpitations. Physical examination of the cardiovascular system revealed a normal pulse rate of 70 beats/min and her blood pressure was 100/60 mmHg. Her lungs were clear on auscultation. There was no pedal oedema or any signs of fluid overload. Routine urine analysis revealed protein 1+, with no sugar, no white cell count and negative nitrites. Renal function test showed mildly elevated creatinine of 138.0 umol/L with estimated glomerular filtration rate (eGFR) of 49mL/min using Cockcroft-Gault equation, sodium of 141.0 mEq/L, potassium (K) 5.2 mEq/L, blood urea 9.7mmol/L. Routine chest X-ray revealed heart apex in the right side and gastric air bubble seen below right hemidiaphragm. Abdominal and pelvic ultrasound revealed the liver presented in the left hypochondrium with normal texture. The spleen was noted in the right hypochondrium with normal texture. The right kidney was normal ∼ 9.7cm in size, the outline was smooth and regular with maintained corticomedullary differentiation, with no hydronephrosis. The left kidney was not visualized. The urinary bladder was normal in outline, distensibility and thickness. The uterus was anteverted with a regular outline and normal endometrial echo complex. Computed tomography scan with contrast of abdomen was done which revealed the liver was present in the left hypochondrium and the spleen was present in the right hypochondrium, inferior vena cava on left side and aorta on the right side. The left kidney and ureter were not visualized. Normal right pelvicalyceal system and excretion from the right kidney were noted. RESULTS The above-mentioned patient did not have any cyanosis, cough, sinusitis, or recurrent chest or urinary tract infections. To diagnose situs inversus, thorough physical examination, chest X-ray, ultrasonography, computed tomography, or magnetic resonance imaging are necessary. These imaging modalities help to evaluate the structures of the internal organs, such as the location of cardiac apex, the site of aorta relative to midline, the location of the stomach, the liver and gallbladder, presence and appearance of the spleens and presence of the kidneys and vascular structures. CONCLUSION Dextrocardia with situs inversus is a rare congenital malformation that must be fully evaluated when there is a suspicion because in some cases it can have deadly results. Apart from detailed medical history and physical examinations, imaging modalities should be used for reaching the diagnosis. Routine and regular follow-ups must be arranged for the patients who have this condition. Patients with unilateral renal agenesis must have regular kidney function tests as well as other modalities when necessary to reduce the chance of deterioration in kidney function and kidney damage.

Bioimpedance spectroscopy: Is a picture worth a thousand words?

Volume status can be difficult to assess in dialysis patients. Peripheral edema, elevated venous pressure, lung crackles, and hypertension are taught as signs of fluid overload, but sensitivity and specificity are poor. Bioimpedance technology has evolved from early single frequency to multifrequency machines which apply spectroscopic analysis (BIS), modeling data to physics-based mixture theory. Bioimpedance plots can aid the evaluation of hydration status and body composition. The challenge remains how to use this information to manage dialysis populations, particularly as interventions to improve over hydration, sarcopenia, and adiposity are not without side effects. It is therefore of no surprise that validation studies for BIS use in peritoneal dialysis patients are limited, and results from clinical trials are inconsistent and conflicting. Despite these limitations, BIS has clinical utility with potential to accurately evaluate small changes in body tissue components. This article explains the information a BIS plot ("picture") can provide and how it can contribute to the overall clinical assessment of a patient. However, it remains the role of the clinician to integrate information and devise treatment strategies to optimize competing patient risks, fluid and nutrition status, effects of high glucose PD fluids on membrane function, and quality of life issues.

Inter- and intradialytic fluid volume changes and vascular stiffness parameters in patients on hemodialysis.

BackgroundWhether fluid overload is associated with vascular stiffness parameters in hemodialysis (HD) patients has not been fully elucidated. We hypothesized that interdialytic fluid accumulation increases vascular stiffness parameters, which improves with intradialytic ultrafiltration.MethodsFluid overload and vascular stiffness parameters were assessed in 39 HD patients (20 with and 19 without fluid overload) and compared to 26 healthy controls. Fluid status was assessed 15 minutes before the mid-week HD session by bio-impedance spectroscopy. Following this, ambulatory pulse wave velocity (PWV) and augmentation index (AIx) were measured for 24 hours before another mid-week HD session and then for 5 hours starting 30 minutes before and ending 30 minutes after the session.ResultsHD patients had significant fluid overload compared to healthy controls (2.0±2.4 vs. -0.2±0.6 L; P<0.001) and baseline PWV was higher (10.3±1.7 vs. 8.8±1.4 m/s; P<0.001). There was no significant difference between PWV and AIx in fluid overloaded and non-fluid overloaded HD patients prior to, or during the HD session. AIx of non-fluid overloaded HD patients improved after the HD session (P = 0.04). Average 24-hour AIx was higher in fluid overloaded HD patients (P<0.001).ConclusionsInter- and intradialytic changes in fluid volume were only weakly related to vascular stiffness parameters in HD patients. Although there was a modest reduction in AIx in non-fluid overloaded HD patients after the dialysis session, fluid removal did not improve vascular stiffness parameters during the HD session. We speculate that the effect of fluid overload correction on vascular stiffness parameters requires long-term adjustments in the vasculature.

POS-523 Incidental Finding of Dextrocardia with Situs Inversus and the absent left kidney in a 55-year-old Nepali woman, a case report

Dextrocardia is an abnormal congenital positioning of the heart: instead of the heart forming in the fetus on the left side, it flips over and forms on the right side. Situs Inversus is a congenital condition in which the main visceral organs are reversed or mirrored from their usual positions. If both conditions are present it is called situs inversus totalis. 54 years old G5P4(2213) woman, government worker presented to an outpatient clinic with complaints of dysuria, frequency, hesitancy, suprapubic burning sensation, and mild chest pain in January 2016. The patient did not have any cardiopulmonary symptoms like chronic coughs, nasal congestion, and palpitations. Physical examination of the cardiovascular system revealed a normal pulse rate of 70 beats per minute and her blood pressure was 100/60mmHg. Her lungs were clear on auscultation. There was no pedal edema or any signs of fluid overload. Routine urine analysis revealed protein 1+, with no sugar, no white cell count, and negative nitrites. Renal function test showed mildly elevated creatinine of 138.0umol/L with eGFR of 49ml/min using Cockcroft-Gault equation, sodium of 141.0 mEq/L, K 5.2mEq/L, blood urea 9.7mmol/L. Routine chest X-ray revealed heart apex in the right side and gastric air bubble seen below right hemidiaphragm. Abdominal and pelvic ultrasound revealed the liver presented in left hypochondrium with normal texture. The spleen was noted in right hypochondrium with normal texture. The right kidney was normal approx 9.7cm in size, the outline was smooth and regular with maintained corticomedullary differentiation, with no hydronephrosis. The left kidney was not visualized. The urinary bladder was normal in outline, distensibility, and thickness. The uterus was anteverted with a regular outline and normal endometrial echo complex. Computed tomography scan with contrast of abdomen was done which revealed the liver was present in the left hypochondrium and the spleen was present in the right hypochondrium, inferior vena cava on left side and aorta on the right side. The left kidney and ureter were not visualized. Normal right pelvicalyceal system and excretion from the right kidney were noted. The above-mentioned patient did not have any cyanosis, cough, sinusitis, or recurrent chest or urinary tract infections. To diagnose situs inversus, thorough physical examination, chest X-ray, ultrasonography, computed tomography, or magnetic resonance imaging are necessary (8,9,10). These imaging modalities help to evaluate the structures of the internal organs, such as the location of cardiac apex, the site of aorta relative to midline, the location of the stomach, the liver, and gallbladder, presence and appearance of the spleens, and presence of the kidneys and vascular structures (8,9,10). Dextrocardia with situs inversus is a rare congenital malformation that must be fully evaluated when there is a suspicion because in some cases it can have deadly results. Apart from detailed medical history and physical examinations, imaging modalities should be used for reaching the diagnosis. Routine and regular follow-ups must be arranged for the patients who have this condition.

112 Safety and biochemical efficacy of sodium–glucose cotransporter 2 inhibitors based on cardiovascular risk profile and volume status in a real-world diabetic population

Abstract Aims Sodium–glucose cotransporter 2 inhibitors (SGLT2i) have become a first-line cardiovascular medication. However, their potential side effects still limit a widespread use in real-world clinical practice. Further, there is uncertainty about the mechanisms mediating SGLT2i-associated cardiovascular benefit. Methods We performed a retrospective analysis on consecutive diabetic patients who were prescribed a SGLT2i in a tertiary referral centre. Patients who completed at least 1 year of treatment were included in the data analysis. Changes in glycated haemoglobin, weight and haematocrit were evaluated and compared across two cardiovascular risk categories, defined through the inclusion criteria of three large randomized clinical trials. Additionally, a modified clinical score (mH2FPEF) was applied to detect the probability of heart failure with preserved ejection fraction (HFpEF). Results Of the 459 patients screened from 2015 to 2020, 312 completed 1 year of treatment (68.0%), 92 interrupted the treatment prematurely (20.0%) and 55 were lost to follow-up (12.0%). The most common causes of drug discontinuation were genital or urinary tract infections (9.4%) and poor glycaemic control (5%). At 1 year, a significant reduction in glycated haemoglobin concentration (−0.6 ± 1.4%, P &amp;lt; 0.001) and body weight (2.4 ± 4.6 Kg, P &amp;lt; 0.001) was observed and was comparable between patients at high vs. low cardiovascular risk. Haematocrit increase at 1 year (2.3 ± 3.3%, P &amp;lt; 0.001) was more marked in patients with high cardiovascular risk and low baseline haematocrit. Among patients with no established heart failure (N = 295), 156 (52.9%) had &amp;gt;50% probability of HFpEF (mH2FPEF ≥3). Conclusions In a real-world population of diabetic patients, SGLT2i were well-tolerated at 1 year and led to improved glycaemic control and weight loss. Haematocrit increase was more consistent in patients with high cardiovascular risk and signs of fluid overload, indicating the potentially beneficial role of euvolemic restoration. More than half of these diabetic patients had a high likelihood of unrecognized HFpEF.

Fluid Therapy in Pulmonary Disease: How Careful Do We Need to Be?

Intravenous fluid therapy is a vital and life-saving therapeutic in veterinary medicine. In the absence of heart or lung disease, trauma or sepsis there is limited evidence that fluid therapy will have a detrimental effect on lung function. In healthy dogs there is a reasonable level of experimental evidence that supraphysiologic rates of fluid are required before signs of fluid overload are made evident. In cats, however, this may not be the case. There are higher rates of asymptomatic myocardial disease, but even in the absence of that it seems that some cats may be susceptible to fluid overload. Where systemic inflammation already exists the careful homeostatic and protective mechanisms within the lung are deranged and increases in hydrostatic pressure are more likely to result in fluid movement into the lung tissues. Strategies including restricting the use of intravenous crystalloid fluid administration and using blood products for management of severe hemorrhage are of increasing importance in human trauma and seem to be associated with fewer pulmonary complications, and lower mortality. Managing dogs and cats with sepsis and acute respiratory distress syndrome is already challenging, but ensuring adequate vascular expansion needs to be balanced with avoiding excessive volume administration which may negatively impact pulmonary function. While fluids remain crucial to management of these conditions, there will be an ongoing requirement to balance need without providing excess. The use of point of care ultrasound may provide clinicians with a non-invasive and accessible way to do this.

MO711COMPARISON OF PERITONEAL DIALYSIS EFFICACY MARKERS IN DIABETIC AND NON-DIABETIC PATIENTS

Abstract Background and Aims Diabetes mellitus (DM) is the leading cause of end-stage kidney disease. Peritoneal dialysis (PD) is an effective and convenient modality of renal replacement therapy, however in diabetic patients, higher technique failure is feared. This cross sectional study aimed to investigate if diabetic patients are good candidates for peritoneal dialysis in terms of dialysis efficacy and volume overload management when compared with non-diabetic patients. Method We conducted a cross-sectional study including 60 patients with end-stage kidney disease currently in peritoneal dialysis. Echocardiography was performed using HDI 5000, allowing M-mode, two-dimensional measurement. Peritoneal equilibration test exam was used to evaluate transport rate and dialysis efficacy. A multifrequency bioimpedance (BIA) analyzer was used. Overhydration (OH) was defined as an extra-cellular water (ECW)/total body water (TBW) over 15%. Clinical and biochemical variables were also explored. Results A total of 60 patients completed evaluation. Overall, 60% (n=36) were males with a mean age of 55,8 ± 15,3 years, BMI 25.9 ± 3.9 kg/m2, 31,7% (n=19) had DM. Median PD vintage was 21 months, automated PD 30%, 8.3% (n=5) were anuric and 10% (n=6) were overhydrated. The median serum N-terminal pro b-type natriuretic peptide (NT-proBNP) level was 1071 pg/mL. Left ventricule (LV) mass index and LV ejection fraction were 129.0 ± 51.1 g/m2 and 62.8 ± 13.0%, respectively. The median excess volume overload was 0.9L. Patients were divided in 2 groups (diabetic and non-diabetic). No differences were found between the 2 groups in terms of time in PD, peritoneal transportation, dialysis efficacy, diuresis, hemoglobin, albumin, normalized protein catabolic rate, hydration status, weight, body mass index, arterial hypertension, chronic heart failure, LV ejection fraction, LV mass index, CA-125 value, clinical signs of fluid overload, systolic and diastolic blood pressure. However, diabetic patients were younger (51,6 versus 58,0; p=0,02), more likely to have peripheral arterial disease (42,1 versus 7,3%, p=0,03), ischemic heart disease (52,6 versus 7,3%, p&amp;lt;0,001) and had higher levels of NT-proBNP (5932 versus 4216 pg/mL, p=0.04). However, when using a multivariable analysis, in a model adjusted to age, residual dialysis, efficacy of dialysis, diabetic patients did not have a significant difference in volume overload, dialysis efficacy and markers of cardiac dysfunction when compared with non-diabetic patients. Conclusion In this population, diabetes was associated with higher levels of NT-proBNP, however it did not translate in higher fluid overload, lower dialysis efficacy or worst cardiac dysfunction, when compared with non-diabetic patients. We conclude that PD is able to control hydration status, dialysis efficacy and cardiac dysfunction in diabetic patients with similar efficiency as in non-diabetic patients.

Sodium-glucose co-transporter 2 inhibition in patients hospitalized for acute decompensated heart failure: rationale for and design of the EMPULSE trial.

AimsTreatment with sodium–glucose co‐transporter 2 (SGLT2) inhibitors improves outcomes in patients with chronic heart failure (HF) with reduced ejection fraction. There is limited experience with the in‐hospital initiation of SGLT2 inhibitors in patients with acute HF (AHF) with or without diabetes. EMPULSE is designed to assess the clinical benefit and safety of the SGLT2 inhibitor empagliflozin compared with placebo in patients hospitalized with AHF.MethodsEMPULSE is a randomized, double‐blind, parallel‐group, placebo‐controlled multinational trial comparing the in‐hospital initiation of empagliflozin (10 mg once daily) with placebo. Approximately 500 patients admitted for AHF with dyspnoea, signs of fluid overload, and elevated natriuretic peptides will be randomized 1:1 stratified to HF status (de‐novo and decompensated chronic HF) to either empagliflozin or placebo at approximately 165 sites across North America, Europe and Asia. Patients will be enrolled regardless of ejection fraction and diabetes status and will be randomized during hospitalization and after stabilization (between 24 h and 5 days after admission), with treatment continued up to 90 days after initiation. The primary outcome is clinical benefit at 90 days, consisting of a composite of all‐cause death, HF events, and ≥5 point change from baseline in Kansas City Cardiomyopathy Questionnaire total symptom score (KCCQ‐TSS), assessed using a ‘win‐ratio’ approach. Secondary outcomes include assessments of safety, change in KCCQ‐TSS from baseline to 90 days and change in natriuretic peptides from baseline to 30 days.ConclusionThe EMPULSE trial will evaluate the clinical benefit and safety of empagliflozin in patients hospitalized for AHF.

Fluid Overload and Mortality in Adult Critical Care Patients-A Systematic Review and Meta-Analysis of Observational Studies.

Fluid administration in combination with the increase in vasopermeability induced by critical illness often results in significant fluid overload in critically ill patients. Recent research indicates that mortality is increased in patients who have received large volumes of fluids. We have systematically reviewed and synthesized the evidence on fluid overload and mortality in critically ill patients and have performed a meta-analysis of available data from observational studies. A systematic search was performed on PubMed, EmBase, and the Cochrane Library databases. All studies were eligible that investigated the impact of fluid overload (defined by weight gain > 5%) or positive cumulative fluid balance on mortality in adult critical care patients. We excluded animal studies and trials in pediatric populations (age < 16 years old), pregnant women, noncritically ill patients, very specific subpopulations of critically ill patients, and on early goal-directed therapy. Randomized controlled trials were only evaluated in the section on systematic review. Assessment followed the Cochrane/meta-analysis of observational trials in epidemiology guidelines for systematic reviews. A total of 31 observational and three randomized controlled trials including 31,076 ICU patients met the inclusion criteria. Only observational studies were included in the meta-analysis. Fluid overload and cumulative fluid balance were both associated with pooled mortality: after 3 days of ICU stay, adjusted relative risk for fluid overload was 8.83 (95% CI, 4.03-19.33), and for cumulative fluid balance 2.15 (95% CI, 1.51-3.07), at any time point, adjusted relative risk for fluid overload was 2.79 (95% CI, 1.55-5.00) and 1.39 (95% CI, 1.15-1.69) for cumulative fluid balance. Fluid overload was associated with mortality in patients with both acute kidney injury (adjusted relative risk, 2.38; 95% CI, 1.75-2.98) and surgery (adjusted relative risk, 6.17; 95% CI, 4.81-7.97). Cumulative fluid balance was linked to mortality in patients with sepsis (adjusted relative risk, 1.66; 95% CI, 1.39-1.98), acute kidney injury (adjusted relative risk, 2.63; 95% CI, 1.30-5.30), and respiratory failure (adjusted relative risk, 1.19; 95% CI, 1.03-1.43). The risk of mortality increased by a factor of 1.19 (95% CI, 1.11-1.28) per liter increase in positive fluid balance. This systematic review and meta-analysis of observational studies reporting adjusted risk estimates suggests that fluid overload and positive cumulative fluid balance are associated with increased mortality in a general population and defined subgroups of critically ill patients.

Fluid Administration in Emergency Room Limited by Lung Ultrasound in Patients with Sepsis: Protocol for a Prospective Phase II Multicenter Randomized Controlled Trial.

BackgroundSepsis remains a major health challenge with high mortality. Adequate volume administration is fundamental for a successful outcome. However, individual fluid needs differ between patients due to varying degrees of systemic vasodilation, circulatory flow maldistribution, and increased vascular permeability. The current fluid resuscitation practice has been questioned. Fluid overload is associated with higher mortality in sepsis. A sign of fluid overload is extravascular lung water, seen as B lines in lung ultrasound. B lines correlate inversely with oxygenation (measured by a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen ie, PaO2/FiO2). Thus, B lines seen by bedside ultrasound may have a role in guiding fluid therapy.ObjectiveWe aim to evaluate if fluid administration guided by lung ultrasound in patients with sepsis in emergency departments will lead to better oxygenation and patient outcomes than those in the standard therapy.MethodsA phase II, multicenter, randomized, open-label, parallel-group, superiority trial will be performed. Patients will be recruited at emergency departments of the participating centers. A total of 340 patients will be randomly allocated to the intervention or standard-of-care group (30mL/kg). The intervention group will receive ultrasound-guided intravenous fluid until 3 B lines appear. The primary outcome will be oxygenation (measured as PaO2/FiO2 ratio) at 48 hours after starting intravenous fluid administration. Secondary outcomes will be patients’ outcome parameters, including oxygenation after 15 mL/kg fluid at 6, 12, 24, and 48 hours; sepsis progress through Sequential Organ Failure Assessment (SOFA) scores; pulmonary edema evaluation; and 30-day mortality.ResultsThe trial will be conducted in accordance with the Declaration of Helsinki. Institutional review board approval will be sought after the participating sites are selected. The protocol will be registered once the institutional review board approval is granted. The trial duration is expected to be 1.5-2.5 years. The study is planned to be performed from 2021 to 2022, with enrollment starting in 2021. First results are expected in 2022. Informed written consent will be obtained before the patient’s enrollment in the study. An interim analysis and data monitoring will ensure the patient safety. The results will be published in a peer-reviewed journal and discussed at international conferences.ConclusionsThis is a protocol for a randomized control trial that aims to evaluate the role of bedside ultrasound in guiding fluid therapy in patients with sepsis via B lines evaluation.International Registered Report Identifier (IRRID)PRR1-10.2196/15997