IVC DIAMETER FOR ESRD VOLUME EVALATION.pptx

IVC DIAMETER FOR ESRD EVALAUATION.pptx

1. "Non-Invasive Ultrasonographic Monitoring of Hemodynamics in Patients Undergoing Regular Hemodialysis" Presented by: Mahmoud Samy Hamdy Atia M.B.B.CH

2. Assistant professor and Head of internal medicine department Faculty of medicine - Suez University Dr . Muhammad Fawzy Musallam Emeritus Professor of Pulmonology- Faculty of Medicine -Suez University Prof . Abdelmonem Elshabrawy Metwally Ibrahim Lecturer of internal medicine Faculty of Medicine -Suez University Dr . Mohamed Mahmoud Elhoseeny

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4. z End-stage renal disease (ESRD) is defined as irreversible decline in the kidney function, which is severe enough to be fatal in the absence of dialysis or transplantation. ESRD refers to individuals with an estimated glomerular filtration rate less than 15 mL per minute per 1.73 m2 body surface area, or those requiring dialysis irrespective of glomerular filtration rate (Fidan and Ağırbaş , 2023). z Worldwide, the number of ESRD persons needing renal replacement therapy (RRT) is estimated between 4.902 and 9.701 million, with the majority occurring in low-to-middle income countries (LMICs) (Fiseha and Osborne, 2023) z In Egypt, the estimated annual incidence of ESRD is around 74 per million and the total prevalence of patients on dialysis is 264 per million (Bayoumi et al., 2019).

5. z Fluid overload is an important factor of morbidity and mortality in hemodialysis patients, and providing normovolemia is an important component of the prescription and sufficiency of hemodialysis (Yildiz et al., 2022). z Hemodialysis (HD) induces significant hemodynamic imbalances due to rapid intravascular volume reduction, fluid and electrolyte shift, often occur simultaneously. This imposes significant stress on the heart and peripheral vasculature and leads to activation of various compensatory mechanisms necessary for the preservation of tissue perfusion ( Doenyas -Barak et al., 2019).

6. z The goal of volume assessment and management is to optimize relative intravascular volume in an attempt to improve cardiac output (CO) and tissue perfusion (Kaptein et al., 2020). z Reliable assessment of relative intravascular volume is essential for appropriate management of patients requiring hemodialysis (HD) and/or ultrafiltration for end-stage renal disease (ESRD), who frequently have mismatch between blood pressure (BP) and intravascular volume, or between extravascular and intravascular volume (Kaptein et al., 2020).

7. z Several techniques have been used in clinic and have shown great impact on fluid evaluation, including biochemical markers, blood volume monitoring, vena cava diameter, bioimpedance spectroscopy, etc.. All these methods may improve the accuracy of fluid evaluation, but none of them has become the gold standard (Yilmaz et al., 2016, Ekinci et al., 2018, Cheng et al., 2022). z There has been a shift from static to dynamic haemodynamic evaluation, and towards 'functional haemodynamic monitoring', a concept wherein preload responsiveness is assessed following a therapeutic challenge of the cardiovascular system ( Scheeren and Ramsay, 2019).

8. z A wide variety of haemodynamic monitoring tools are available. Several less or even non-invasive monitoring techniques have emerged, in a continuous pursuit to obtain accurate and reproducible indices, while minimizing the risk of catheter-related complications associated with invasive techniques. In light of this, spectral carotid Doppler ultrasound (CDU), a non-invasive haemodynamic monitoring tool, has gained increasing popularity (Beier et al., 2020). Ultrasound (US) machines capable of performing CDU are nowadays readily available in many operating rooms, emergency departments, and intensive care units (ICU). These favourable characteristics qualify CDU as a safe and cost-effective bedside alternative to support the clinician in early diagnosis and clinical decision making (Kenny, 2021).

9. However, currently available CDU literature shows a large heterogeneity regarding patient selection, the purpose of assessment, and study design, with often contradictory findings. With this narrative review article, we aim to clarify the current status of CDU as a haemodynamic monitoring tool. Firstly, the CDU equipment, clinical procedures and derived parameters are described. Following, the role of pharmaceutical and cerebral autoregulatory mechanisms on carotid blood flow ( cBF ), and their implications on the applicability of CDU are discussed.

10. z The available evidence regarding the clinical applicability of CDU within three haemodynamic domains: cardiac output (CO), volume status (VS), and fluid responsiveness (FR) assessment, and informs on the validity of CDU within different patient groups (Suriani et al., 2023). Inferior vena cava ultrasound (IVC US) assessment of relative intravascular volume to guide volume management. IVC US may be a useful tool for predicting whether critically ill patients are likely to tolerate volume removal with hemodialysis (HD) and ultrafiltration (UF) (Kaptein et al., 2018).

11. z One alternative approach is the utilization of transthoracic lung ultrasound. A score based on the number of B lines accurately measures the degree of lung congestion and may guide ultrafiltration rate (Ross et al., 2018). In addition, the rate of disappearance of B lines during intermittent hemodialysis shows a good correlation with the volume of ultrafiltration and dry weight (Miao et al., 2021).

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13. aim of the work was To Illustrate the value of using non-invasive Ultrasonographic Monitoring of Hemodynamics in Patients Undergoing Regular Hemodialysis.

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15. Subjects & Methods Study Design A Cross sectional descriptive and analytical study.

16. Subjects & Methods Study Settings The study will be carried out at the internal medicine Department (Hemodialysis unit), Mobaret Almahalla Hospial , Health Insurance.

17. • Age > 18 years. Inclusion criteria: • All patients on regular HD for at least 3 months. Exclusion criteria: • Age ≤ 18 years . • Malignancy. • Active infection. • Patients on irregular hemodialysis.. • Patients on hemodialysis less than 3 months.

18. Detailed methodology

19. History taking - Demographic data: age, sex, special habits, marital status, occupation. - Aetiology of renal failure and duration of dialysis.. - Past medical history: Associated comorbidities and medication history. - Social history: smoking, alcohol, recreational drugs, accommodation and living arrangements, marital status, baseline functioning, occupation, pets and hobbies. - Systems review: cardiovascular, respiratory, gastrointestinal, nervous, musculoskeletal and genitourinary systems. - Family history: especially parents, siblings and children. - Dialysis prescription data included the duration of dialysis, total fluid removed and ultrafiltration rate (expressed as liter of fluid removed per kilogram weight per hour).

20. Examination - Vital signs (Temperature, Blood pressure, Pulse, Respiratory rate). - Reviewing of different body systems for detection of signs of uremia. - Detailed abdominal examination will be done for further evaluation of the kidney condition. - Ambulatory blood pressure monitoring. - Beginning one hour before HD, blood pressure will be measured at 15-min intervals using an ambulatory blood pressure monitoring (ABPM) device (Mobil-Q-Graph New Generation 24h ABP-Control, I.E.M. GmbH. Stolberg, Germany) during HD and subsequent one hour.

21. Laboratory investigations • Complete blood count. • Liver function tests ( serum bilirubin (total and direct), serum albumin, serum alanine transferase and . aspartate transferase) • Kidney function tests (KFT) : ( serum creatinine , serum urea nitrogen ) • Bleeding profile: (PT, PTT, INR) • Random blood glucose level •

22. Laboratory investigations • Serum Electrolytes S. Ca , Po4 , uric acid , Mg , K , Na • Urine output, urine analysis • Arterial blood gases (ABG) • Inflammatory markers : ESR and CRP • Triglycerides, LDL and HDL Fasting Lipid profile, including total cholesterol • Estimated GFR will be calculated by using the Cockcroft-Gault formula (Cockcroft and Gault, 1976). • eGFR (mL/min/1.73 m2) = {((l 40–age) x weight)/(72xSCr)}.x 0.85 (if female)

23. Radiological investigations 1- Renal ultrasonography to evaluate kidney size, echogenicity corticomedullary differentiation and exclude obstruction. 2- Vena Cava Collapsibility Measurement: A Sonosite M-turbo (Bothell, WA, USA) ultrasound machine will be used to evaluate the vena cava collapsibility. The patients underwent a bedside ultrasound examination immediately before their dialysis sessions, in the supine position with 30° inclination.

24. Radiological investigations 2- Vena Cava Collapsibility Measurement: The probe will be placed in the subxiphoid region and a sagittal view of the inferior vena cava (IVC) will be obtained by B-mode ultrasonography, just below the diaphragm in the hepatic segment. - T he maximal IVC diameter ( IVCmax ) during passive expiration - T he minimum IVC diameter ( IVCmin ) will be measured during inspiration - The indexed IVC expiratory diameter ( VCDi ) will be calculated by dividing the IVCmax (in mm) by the body surface area (in m2).

25. Radiological investigations 3- Performing a CDU examination The examiner sits on the lateral or cranial side of the patient, who is in a supine position, with the head rotated 30–45° to the contralateral side to fully expose the neck. Applying excessive pressure on the neck with the transducer should be avoided to prevent patient discomfort, unnecessary vessel manipulation possibly leading to reflex bradycardia due to carotid baroreceptors stimulation, and altered aperture-to-depth ratios which may lead to spectral broadening errors. (Suriani et al., 2023).

26. 04 Ethical considerations

27. z The selection of patients will be done after prior explanation of the aim of the study, and free well-written approval consent will be taken, and the whole work will be done according to the ethical committee, Faculty of medicine, Suez University.

28. 05 Statistical analysis

29. ● The collected data will be coded, processed and analyzed using the SPSS (Statistical Package for Social Sciences) version 27 for Windows® (IBM SPSS Inc, Chicago, IL, USA). ● Qualitative data will be described in the form of number and percentage while quantitative data will be expressed as mean± SD or median (range) according to normality. The appropriate statistical tests will be used according to the nature of the data. ● A P< 0.05 will be considered statistically significant.

30. 06 Conclusion

31. Conclusion **Doppler Ultrasound**    - Assessment of Cardiac Function    - Vascular Assessment 2 . **Ultrasound for Volume Status**    - Inferior Vena Cava (IVC) Measurement   - Lung Ultrasound 3. **Monitoring Hemodynamics**    - Blood Pressure Assessment    - Cardiac Output Measurement 4 . **Fluid Responsiveness**    - Dynamic Parameters