Importance of the curve shape for interpretation of blood volume monitor changes during haemodiafiltration
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BRIEF REPORT
Importance of the curve shape for interpretation of blood volume monitor changes during haemodiafiltration Céline Dheu & Joelle Terzic & Soraya Menouer & Michel Fischbach
Received: 8 September 2008 / Revised: 22 January 2009 / Accepted: 28 January 2009 / Published online: 7 March 2009 # IPNA 2009
Abstract In children, the prescribed ultrafiltration needed to achieve the fixed end session dry weight can induce hypotensive episodes. A variety of on-line devices based on the direct measurement of the hematocrit are available, but these devices nearly always only measure the quantitative variation in the blood volume as the means of identifying a hypotensive occurrence risk. In February 2002, our unit began using an on-line hematocrit measurement available even with infants’ blood lines. Since January 2004, this blood volume monitor (BVM) has been used routinely in all dialysis sessions, and 2240 BVM data sets have been recorded and analysed during the last 4 years. Based on our analysis of these data sets, we have determined that, in addition to the described threshold points, which provide a quantitative analysis of the BVM, the qualitative analysis of the BVM, the so-called curve shape, is also of clinical importance. In 91% of the sessions analysed, a very similar “symptom-free” curve shape was noted that consisted of an initial decrease, followed by the BV reaching a “stable” plateau. Additional curve shapes were identified: one with no BV decrease, presumably indicating an overload risk state, and one with a continuous BV decrease, presumably indicating an hypovolemic risk state. In our experience, only 2% of the patients had relevant clinical symptoms that were not visible by BVM. Keywords Blood volume . Children . Curve shape . Haemodiafiltration
C. Dheu : J. Terzic : S. Menouer : M. Fischbach (*) Nephrology Dialysis Children Unit, University Hospital, Avenue Molière, 67098 Strasbourg Cedex, France e-mail: [email protected]
Introduction Concerns about the inadequacy of blood volume (BV) management are a challenge for physicians dealing with haemodialysis (HD). The goal of optimal ultrafiltration (UF) during HD is to remove most of the excess body fluid to reach the appropriate dry weight [1, 2]. While challenging in adults, assessment of dry weight is even more difficult in paediatric HD patients because children are still growing and have a variable appetite due to dietary restrictions. Intradialytic hypotension due to intravascular volume depletion is one of the most common complications of HD [2, 3]. Conversely, inadequate removal of fluid may lead to chronic overload manifested in hypertension, left ventricular hypertrophy and congestive heart failure, ultimately leading to a poor cardiovascular prognosis [4–7]. Since intradialytic symptoms are not always accompanied by blood pressure changes, continuous monitoring of blood pressure during HD may be a poor predictor of hypovolemic status. Moreover, in small children, the onset of hypotension episodes is very rapid, and youn
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