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Slow continuous ultrafiltration: how many fluids must be taken out?

Introduction

Ultrafiltration (UF) is effective and safe in treating volume-overloaded patients with acute decompensated heart failure (ADHF) and diuretic resistance [1]. Accurate determination of the amount of fluid to be removed and maintenance of the circulating blood volume are critically important [2]. The inferior vena cava diameter (IVCD) and its collapsibility index (IVCCI) are compromised in ADHF patients due to high right atrial pressure [3]. We hypothesized that monitoring of IVCCI could be used to optimize fluid removal rate during UF.

Methods

Twenty patients (nine male, 11 female; age 76 ± 4, New York Heart Association classes III to IV) admitted to our medical ICU for ADHF were treated with UF (Aquadex System 100; CHF Solutions, Minneapolis, MN, USA). The heart rate (HR), mean arterial pressure (MAP) and IVCD with M-mode subcostal echocardiography during spontaneous breathing were evaluated before UF (T0), at 12 hours (T1) and at 24 hours (T2). The IVCCI was calculated as follows: [(IVCDmax – IVCDmin)/IVCDmax] × 100.

Results

The mean UF time was 25.5 ± 5 hours with a mean volume of 259 ml/hour and a total ultrafiltrate production of 6.6 ± 2 l. Differences between the T0 and T2 parameters are presented in Table 1. Hypotension was observed only in those patients (2/20) who reached IVCCI >35%. In all the other patients a significant increase in IVCCI was obtained without any hemodynamic instability.

Table 1 (abstract P277)

Conclusion

Inferior vena cava ultrasound is a rapid, simple and noninvasive means for bedside monitoring of the intravascular volume during UF.

References

  1. 1.

    Costanzo RM, et al.: Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol 2007, 49: 675-683. 10.1016/j.jacc.2006.07.073

  2. 2.

    Ronco C, et al.: Extracorporeal ultrafiltration for the treatment of overhydration and congestive heart failure. Cardiology 2001, 96: 155-168. 10.1159/000047399

  3. 3.

    Blehar DJ, et al.: Identification of congestive heart failure via respiratory variation of inferior vena cava diameter. Am J Emerg Med 2009, 27: 71-75. 10.1016/j.ajem.2008.01.002

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Guiotto, G., Gligorova, S., Paladino, F. et al. Slow continuous ultrafiltration: how many fluids must be taken out?. Crit Care 13, P277 (2009). https://doi.org/10.1186/cc7441

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Keywords

  • Mean Arterial Pressure
  • Spontaneous Breathing
  • Acute Decompensated Heart Failure
  • Circulate Blood Volume
  • York Heart Association Class