Beruflich Dokumente
Kultur Dokumente
Abnormalities
in Septic and Critically Ill
Patients Using a Newly Designed
Indwelling Thermodilution
Renal Vein
Catheter*
Matthew
Anthony
Brenner,
M.D.;
Gary
L. Schaer,
F. Suffredini,
M.D.;
andJoseph
M.D.;
Douglas
L. Mallory,
E. ThrriIIO,
M.D.
To evaluate
alterations
in renal
blood flow in sepsis-induced
renal
failure,
we developed
and studied
a percutaneously
placed
thermodilution
renal blood flow catheter
in eight
critically
ill patients.
Para-aminohippurate
extraction
coefficients
were decreased,
supporting
the need for renal
vein sampling
to determine
C,
in sepsis. Thermodilution
and CPAH methods
correlated
strongly,
confirming
the reliability
of this thermodilution
method,
Renal
vascular
resistance,
an indicator
ofrenal
vascular
function,
remained
unchanged
throughout
the bouts of sepsis
The fraction
of
total
body
arterial
blood
flow going to the kidneys
rose
significantly
during
recovery
from sepsis. Glomerular
flutration
rate, which
was reduced
in four of seven septic
patients,
correlated
with the fraction
of total blood
flow
going
to the kidneys.
These
results
suggest
that
renal
eptic
shock
complicating
is the leading
death
in intensive
tion
develops
severe
frequently
in
hemodynamic
patients
increased
infection
abnormalities
potentially
nephrotoxic
ute to the development
mortality
of sepsis-induced
of renal
function
nism
injury
of acute
and
may
ology
ofrenal
*Fmm
the
National
Critical
in critically
play
failure
Care
the
use
of
a central
role
leading
to
the preser-
ill patients.
in renal
blood
flow are
renal
failure
in animal
Alterations
is
vasoactive
agents
may contribof renal
failure.
The
high
renal
failure
underscores
the need
to understand
the mechanisms
renal
failure
and to develop
methods
for
vation
and
mortality.3
with
the
and
a major
models
in the
in septic
patients.
Medicine
Department,
abnormalities
shock.
Our
study
dysfunction
blood
may
flow
alterations
Clinical
Institutes
in part
Center,
ofHealth,
Bethesda,
MD.
Presented
at the annual
meeting,
American
Federation
for
Clinical
Research,
San Diego,
CA, May 1987,
and the 16th Annual
Educational
and Scientific
Symposium,
Society
of Critical
Care
Medicine,
Anaheim,
CA, May 1987.
Published
in abstract
form in
Clin Bes 1987;34:884a,
and Crit Care Med 1987;i5:435.
Manuscript
received
October
26; revision
accepted
January
31,
1990.
Reprint
requests:
Dr. Brenner,
Bldg 53, Pan 199, Pulmonary
and
Critical
Care,
UC/MC,
101 City Drive
South,
Orange,
CA 92714
170
may
demonstrates
occur
during
be
during
septic
sepsis-induced
renal
ranges
of total renal
(Chest
1990; 98:170-79)
occurring
that
despite
normal
shock.
CC (in vitro)computation
constant
for in vitro
fluid
flow;
CPAH=clearance
ofpara-aminohippurate;
CIcorrection
factar for in vitro fluid flows (CC/[60JV1);
ERPFeffecdve
renal
plasma
flow;
GFRglomenilar
filtration
rate; PAll
paraaminohippurate;
RBF
renal
blood
flow; RVR
renal
vascular
resistance;
Thtemperature
of blood; Tltemperature
of
injectate;
VIvolume
ofinjectate;
Up
urinary
PAH concentration;
V
= urine volume;
Art,
arterial
PAll
concentration; Ven,venous
PAH concentration;
Uurinary
inulin
concentrafion
Vurine
volume;
Art,.arterial
inulin
concentration
events
blood
blood
flow
may
be
sufficient
to initiate
the
which
lead to renal failure.7
The role of altered
flow in the pathogenesis
of renal dysfunction
in
humans
remains
limitations
difficult
associated
to characterize
with
the
because
measurement
of
of renal
flow during
sepsis.
Although
urine
output
is
used clinically
to evaluate
shock,
urine
flow does not
closely
correlate
with
renal
blood
flow. A standard
method
of estimating
total renal blood
flow in healthy
blood
persons
is the CPAH ,8 Creater
than 90 percent
of PAH
is removed
from the circulation
during
a single passage
through
the kidneys
in normal
humans.
This almost
complete
mechaof renal
pathophysi-
Brief
vascular
in renal
infections
organ
failure
and
Renal dysfunc-
septic
associated
with a substantially
The
severity
of the underlying
resultant
bacterial
cause
of multiple
care unit pats2
M.D.;
removal
of PAH
results
accurately
estimate
overall
renal
sepsis
reduces
PAH extraction
mechanisms.&la
This
decrease
ing sepsis
thus introduces
blood
flow determination.
in clearances
that
blood
flow. However,
through
a variety
of
in PAH
extraction
serious
errors
Additionally,
dur-
in the renal
the time
re-
quired
for equilibration
of indicator
levels
for the
clearance
method
measurements
limits the use of CPAH
in the intensive
care unit where
frequent
physiologic
changes
require
rapid,
reproducible
methods
of meas-
1 1, 12, 1922
We
which
have
developed
a specially
is placed
percutaneously
Renal
m Septic
shaped
catheter
under
fluoroscopic
and Critically
III (Brenner
et a!)
/(0cm
Injectate
Opening
Port
(Opening
Convex
on
Portion
of
Catheter
Curve(
FIGURE
1. Design
of RBF
catheter
used
in present
study.
The
catheter
has a 180#{176}
bend
in the catheter
2 cm from the distal
end
designed
to curl the tip into the renal
vein orifice,
and a 45#{176}
bend
6 cm from the distal
tip to allow access
to the renal vein.
guidance
into
the
renal
vein.
The
placement
catheter
in the renal
vein allows
direct
renal venous
blood,
and determinations
ovenous
PAH
accurate
results
extraction
can
calculations
of our experience
be
of the
sampling
of
of the arteri-
performed,
allowing
of CPA,, We report
herein
the
with this renal vein catheter.
.
Further
development
of such techniques
should
vide a means
for measuring
serial thermodilution
renal
CPAH
blood
flow
measurements
proand
in critically
ill
patients.
MATERIALS
Catheter
AND
METHODS
Design
The
catheter
(Critikon
was
designed
Corporation,
polyvinylchloride
a rapid
with
Tampa,
catheters,
response
FL):
with
thermistor
the
5-F,
100cm
with
following
double
standard
catheter
is fashioned
with
a i80
bend
allowing
the
tip to curl
within
bend
6 cm
tip allows
access
the
distal
containing
Edwards
end,
from
radiopaque
ofusablelength,
The
catheter
specifications
lumen,
connectors.
2 cm
from
the
renal
to the
the
distal
vein.
renal
A 45#{176}
vein
(Fig
1).
Catheter
Calibration
of
the
catheter
determined
rates
was
against
a range
a plastic
tubing
constants
were
Patient
( seven
and
of standard
system
the
accuracy
flow
(Appendix
The
computation
catheter-determined
determined
November
with
and
accuracy
constants
were
thermodilution
rates
of fluid
flow
pumped
1). Thermodilution
through
computation
1985
septic
concurrent
medical
protocol
Review
Board
informed
Septic
shock
to April
shock)
care
was
entry
>38#{176}C, hypotension
eight
serial
hemodynamic
unit
at the
approved
at the
written
1987,
underwent
systemic
intensive
study
gave
to verify
measurements.
Population
From
and
validated
by comparing
used
National
by
National
the
critically
function
function
studies
Institutes
Institutional
Institutes
ill patients
renal
in
of Health
the
. The
Human
Research
and
all patients
of Health
FICuIIF:
studies
consent.
criteria
(mean
were
defined
arterial
(a) temperature
as either:
pressure
<60
mm
Hg,
or
2. (]p7)er:
Diagran
repres(IIting
tle in tzr() 15)sition
of the
veit, catluter
vlie,,
pLoced
ptrcntaiucnislv
froiis the ftnural
vein into) the r-,,al
vein. ( ld injectali
exits
tIn r(!htl vei,i (athettr
tt the site
lalkd
iIijtctott
s)rt
.
dfl(l ))d%S(S
tl
tlarnistor
as
blood
fIovs into
tlit inferior
veii cava (I().
( atl,ettr
I))rts
ot the
injectate
dII(l tliorinistor
sites allov
renal tjti
sanipling
for accurate
deternunatn)n
( )1 IA1
I txtraction
c vihcio,its.
Ii;ieer:
Alxh,niual
radiograph
sln)viIIg tl,trenal
eii (atl,rt(r in tIe correct
Is)sitn)II
for RBF (loterlninatit)Il
H, the left rtntl
iiu ola criticall
ill 1)Lt1(Ilt.
renal
CHEST
I 98
I 1 I JULY,
1990
171
greater
and
than
50
pressure
<60
pressure
mm)
Hg,
than
were
Hemodynamic
Arterial
artery
patient
Thermodilution
Serial
monitored
its
measurements
thermodilution
wedge
capillary
paper
was
wedge
venous
cardiac
Hg])
x &V(CO).
vein
output
made
index
from
and
systemic
to standard
Renal
x 80/RBF
(IJmin)(,,,,,
by
the
of
the
on
vascular
formulas:
CI
(11
[mm
sive.
If the
renol
was
added,
mm.
All
patients
was
patient
added
ifthe
>20
pg/kg
required
and
the
received
was
blood
culture
results
adjusted
accordingly.
maintain
a normal
including
phosphate,
sterile
Miami,
guidance.
was
oxygen
renal
were
determined
promptly
corrected.
port,
in the
PAH
and
Inulin
for
and
were
each
evaluations
were
mid-
For
each
of room
tern-
values
were
low
averaged.
Thermo-
injection.
Concurrent
with
obtained
each
of
set
RBFs.
and
Concurrent
Renal
RBFs,
Measurements
inulin
evaluations
intensive
to 72 h when
care
feasible
clearances,
were
and
obtained
unit
for shock
(Fig
3).
complete
within
and
systemic
18 h of admission
repeated
over
the
next
24
Analysis
statistics
ranges.
Initial
using
two-tailed
variables
and
are
paired
were
reported
follow-up
assessed
as means
values
t tests.
using
were
standard
compared
Correlations
linear
errors
among
between
regression
and
patients
continuous
analysis.
RESULTS
Catheter
Calibration
and
Thermodilution
catheter
strongly
(r = 0.997,
Computation
amounts
collected
(Appendix
shown
measurements
p<O.OOl)
when
volumetrically
correlated
with the
compared
in the
in vitro
to 2,500
system
were
from
150
mI/mm.
vein
vein
site
length.
in samples
ofa
was
in
the
was
No other
to accommodate
vessels
the
catheter
caval
samples
the
cava.
ofthe
vein
high
renal
and
standard methods
measurements
were made:
age = 100
x (arterial,PAH,
flows
were
mulin
clearance
(Appendix
in
that
the
The
renal
vein
of the
renal
use
PAH
renal
corrected
extraction
vein
are
for the
decreased
were
following
coefficient
Thermodilution
Renal
Flow Determinations
90
120
derived
percentEffective
extraction
172
of
Blood
catheter
determinations
vein(PAHI)/artenal,PARI
60
Inulin
Bolus
and Infusion
of
catheter.
The
fernoral
Clearances
using
(mins)
Systemic
Hemodynamic
Determinations
change
to confism
in the area
renal
(c)
the
vena
Collection
Period
PAH Bolus
and Infusion
blood
abdominal
and
into
used
the placement
to confirm
(a)
temperature
inferior
2nd
position-
vena
injected
detectable
thermistor
not
from
Time
passed
for renal
by
obtained
solution
was
curve,
drawn
1st Collection
Period
Period
fluoroscopic
Correct
confirmed
Equilibration
Co.
percutaneously
under
preferred
was
infiltrated
(Cordis
catheter
thermodilution
cold saline
the absence
Para-aminohippurate
plasma
the
locally
vein
vein
renal
to concurrently
dye
enough
renal
characteristic
not necessary.
large
was
was
fernoral
of its greater
saturation
When
fluoroscopic
renal
paramcreatinine,
introducer
renal
the
into
vein
area
the
The
because
in comparison
2).
femoral
into
and
made
to
nitrogen,
glucose,
high
outputs
obtained
at the
inulin.
injections
The
five
and
Determination
were
as needed
Metabolic
urea
a 6-French
technique.
left
(b)
introducer
the
introduced
catheter
radiograph,
was
percent.
and
agents
given
abnormalities
and
introducer
The
ing ofthe
(Fig
was
blood
magnesium
lidocaine
measurements
ports
electrolytes,
any treatable
Seldinger
the
venous
antibiotic
support
an SaO,>90
procedures,
FL)
the
through
flow
the
Obtained,
and
serum
1 percent
using
were
hemodynamic
Hemodynamic
to the
hand-force
obtained.
obtained
for PAH
Placement
Using
with
were
calcium,
Catheter
curves
In Vitro
levarte-
to 2 to 3 pg/kg
antibiotic
coverage,
a cephalosporin,
and a semiPseudomonas
aeruglnosa.
When
Respiratory
pH
4 to 8 h and
every
were
were
period
maximal
broad-spectrum
usually including
an aminoglycoside,
synthetic
penicillin
active
against
ERPF/
hypoten-
of dopamine,
tapered
PAH)
Flow Determinations
collection
D5W
Statistical
remained
mlii
dopamine
RBF(,,,,,,.,J
as =(MAP-
PAH ..*bd)
patient
coefficient.
extraction
as:
determinations
perature
Descriptive
Dopamine
Blood
discarded
hemodynamic
30-mm
thermodilution
Protocol
15 mm
CPAH/PAH
calculated
RBF
seven
complete
tracings
pressure)
Renal
ofeach
dilution
pressure,
Measurements
were
according
artery
radiographically.
(m),
renal
Treatment
and
Cardiac
calculated
were
min/m)=CO/BSA
in the pulmonary
obtained.
pressure
cath-
A pulmonary
confirmed
pressure
were
at end-expiration.
resistance
arterial
patients.
6 to 8 h) of central
technique
pulmonary
in all
was placed
position
(every
capillary
pulmonary
via an indwelling
artery
ERPF
was
Thermodilution
determination,
catheter
and
formula:
flow
cells/cub
to concomitant
antibiotics.
or femoral
flotation
balloon
of each
was
radial
the
blood
(1-hematocrit).
Evaluations
pressure
in the
eters,
using
Renal
in systolic
<500
ascribed
PAH
arterial
decrease
(neutrophils
that
baseline),
(mean
50 mm
neutropenia
cultures
broad-spectrum
from
hypotension
point
Systemic
graph
pressure
fever,
or greater
blood
with
in systolic
(b)
or
baseline),
negative
treatment
decrease
cultures,
mm
from
and
eter
mm
blood
positive
FIGURE
3. Protocol
for concurrent
measurement
of RBF and GFR
determination
by CPAH , inulin
clearance
and thermodilution
methods. lIme
in minutes
is depicted
on the horizontal
line; PAH and
inulin
boluses
were
administered
at time
0, followed
immediately
by continuous
infusions
ofboth,
After a 60-mm
equilibration
period,
two 30-mm
collection
periods
were
begun;
PAH and inulin
level
were obtained
from urine,
arterial,
and renal vein blood samples
at
60, 90 and 120 mm.
Systemic
hemodynarnic
and thermodilution
RBF measurements
were obtained
midway
through
each collection
period
at 75 and 110 mm.
Renal
Blood
Flow
Abnormalities
in Septic
and Critically
Ill (Brenneretsi)
12 determinations
in six patients;
blood
flow
at the time
of 112
to
1,767
mI/min
mm) by corrected
up evaluation,
after
CPAH.
patients
to a mean
of 737
4,E]).
Renal
15,600
did
not
5,822
systemic
hemodynamic
at the
Renal
blood
flow
There
dosage
179
p>O.2O).
directly
with
(CI,
also
was
no
did
SVR
not
any
or arterial
The
change
to the kidneys
(RBF/
(Fig 4,H [p<O.O5fl.
correlate
correlation
with
between
kidneys
in any of these
or changes
pressor
during
Glomerular
filtration
four
was
ofseven
reduced
septic
rate
patients.
(range,
18 to 126 mI/mm).
significantly
(0.36 mg/dL
the
first
24 h of shock
filtration
(r =
Initial
Serum
by
<60
GFR
inulin
mI/mm)
varied
in
in these
levels rose
p = 0.012)
within
patients.
of total
blood
flow
r = 0.92,
p = 0.003
Glomerular
filtration
rate
determinations.
did
not
change
going
[Fig
the feasibility
in critically
to
7]).
signfficantly
the
Gbon
a variety
confirm
accurate
including
vein
need
for renal
catheters
unit.
reducdue to
with
renal
Our results
are
PAH kinetics
catheterization
of RBF;
for these
PAH
strong
correlation
p<O.05)
across
patients
Renal
(112 to
hemodynamics
in
the
RBF among
found
decreases
in significant
lution-determined
for
extractions
was
found
RBF
and
wide
range
1,767
in PAH
errors
in the
thermodi-
methods
ofbbood
extrac-
estimation
between
CPAH
(r = 0.79,
flows
in these
mI/mm
blood
flow; [Fig 5]).
demonstrated
large
variability
patients
with
sepsis,
by previous
12,
similar
to results
No direct
correla-
flow
between
vascular
resistance
the
oftotal
going
to the
initial
and
index
did
study
findings
and
suggest
occurring
The overall
for the patients
documents
vein
care
interference
the
ring to a corresponding
It is unknown
whether
priate
renal vascular
and
variable
patients
flow817
ofaltered
result
vasodilation
0
study
shunting
ofbbood
with observations
to account
tion would
of RBF.
throughout
LU
This
CPAH
ranged
from 28 to 90 percent
in our patients
(mean,
55.7 5.6 percent;
normal
values
exceed
90 percent).
These
rr
that
The
indwelling
renal
in the intensive
determination
as systemic
vascular
RBF.
of causes
catheter
ill patients.
of using
ill patients
significantly
vein
critically
PAH secretion
secondary
to tubular
dysfunction,
competition
for anionic
secretory
sites by drugs,
interference
of assay measurements
by various
medications,
fraction
LU
renal
and
Previous
investigators
have found
tions in renal PAH extraction
in septic
creatinine
increase,
in septic
catheter
can determine
bevels (with extraction
widely
with
the fraction
kidneys
(RBF/CO;
follow-up
GFR,
rate
0.505;
merular
determined
(initial
developed
RBF
Failure
recovery.
clearance
measures
and
dopammne
parameters
have
and possibly
in agreement
or levophed
dosage
and initial
RBF, follow-up
value,
percentage
of blood
flow going
to the
RBF
We
thermodilution-derived
[Fig
of follow-up
evaluation.
flow going
of follow-up
mI/
on followin septic
(p<O.O5
time
correlate
of initial
DISCussIoN
averaged
evaluation
and
dynes.s.cm,
not
parameter
time
in the fraction
ofblood
CO)
rose at the time
dosage.
mL/min
at the
3,365
did
percent
among
with a
690
resistance
on initial
significantly
(11,050
blood
flow
pressure)
(mean,
168
dynes.s.cm
evaluation
Renal
>90
Renal
blood
flow
24 to 72 h, increased
vascular
change
normal,
varied
considerably
of initial
evaluation
blood
increased
not change
did
not
that
the
in septic
increased
measurements,
(p<O.05).
Renal
significantly
correlate
with
profound
patients
SVR.
systemic
is not
occur-
degree
in the renal vasculature.
these findings
represent
approregulatory
functions.
adequacy
in our
flow
kidneys
final
going
of RBF is difficult
to assess
study.
The rise in the fraction
to the
kidneys
during
recovery
from
sepsis
suggests
that
the
vasodilation
in the
systemic
circulation
during
the initial
phase
of the
septic episode
was not matched
in the renal circulation.
10
RBF/CO
FIGURE
7. Correlation
to the kidneys
with
correlation
coefficient
20
these
total blood
flow
phase
of sepsis.
(%)
ofthe
initial fraction
oftotal
blood
GFR (by inulin
clearance)
in septic
of0.92
was obtained
(p=0.003).
As a result,
flow going
patients.
A
dilation
blood
occurred
patients
had
fraction
of their
in a higher
fraction
acute
vaso-
of renal
flow
CHEST
a lower
I 98 I I I JULY, 1990
175
1600
m2).
C
E
:Do
6Li
1200
following
recovery
(Fig
improved
clinically
when
an average
800
sure
Y=553+0.53X
R=0.79
600
mm
(from
P=0.036
w
400
dilI.c
1000
2000
5.
Correlation
BLOOD
ofinitial
RBFs
in milliliters
FLOW
(mi/mm)
measured
coefficient
obtained
with
a slope
of 0.47
(p<0.01).
Although
RBFs overestimated
PAH-determined
blood
flows
and underestimated
blood
flow at high rates,
this could
for by the regression
equation.
thermodilution
at low rates
be corrected
decreased
(p = NS)
toward
(Fig 4,A).
between
thermodilution
and
Renal
flow
blood
1.04)
according
to the standard
protocol.
At the conclusion
of the
dosages
ranged
from
0 to 2 pq,/kg/
min (mean,
0.57 p.g/kg/min,
SEM,
0.36).
Initial
RBF
did not correlate
with the
mine
dose
change
in
did
not
r =
0.25)
(p = 0. 129;
RBF from
correlate
or the
r = 0.630).
onset
with
change
initial
dopamine
in dopamine
also
Hg) (p<0.05).
at follow-up)
and
Renal
Carhad
significantly
occurred
or pulmonary
the study
period.
Renal
12.5
significanfly
normal,
though
not
No signfficant
change
vascular
normal
to
blood
pres-
in
capillary
Function:
Blood
by
Flow
Methods
determined
by
the
degrees
at the
evaluation
studied
(mean,
ofinitial
56.3 percent;
thermodilution
the
corrected
C
PAH extracreduced
to variable
with
51). The
range,
in the
patients
28 to 90 percent;
100
also
(pO.66;
dosage
with
80
0
0
l-z
r=0.60).
<LU
Only
during
tically.
levophed
two patients
were
on levophed
at any time
the study,
making
it difficult
to evaluate
statisHowever,
the patient
on the highest
dose
of
during
the initial
measurement
(9 p.g/min)
the
study)
been
smallest
Renal
All patients
ments
change
at the time
discontinued.
Baseline
in RBF
of recovery
0-u-
60
-LU
had
<C-)
ch
had
baseline
within
serum
36 h prior
creatimne
measure-
to the onset
20
of sepsis.
level less
1.45; SEM,
0
The
Hemodynamic
systemic
with
40
Function
obtained
Systemic
in the
all pressors
All
tients
increased
mm
IJmin/m2
recovery
(p = 0.226;
r = 0.58).
Dopamine
concentrations
also did not correlate
with
the GFR
(p = 0.20;
had
Systolic
MAP
had
after
the
to follow-up
dose
patient
6.4 to 127.3
[Fig
were
time
one
at follow-up
correlated
strongly
clearance
(r = 0.79,
p<O.O5
tion coefficient
percentages
dopa-
Additionally,
of sepsis
but
toward
106.5
method
pg/kg/min;
SEM,
patient
therapeutic
study,
dopamine
All
from
5.0
Hemodynamics
Correlation
199
24 to 72 h). Systemic
to 86.06.5
(mean,
Hg),
reduced
during
the
with levels obtained
(p<0.01).
and
71.93.6
index
Renal
by thermodilution
A correlation
perminute.
p<O.OS)
mm
(565
6.4
SVR
evaluated
pulmonary
artery
pressures,
wedge
pressure
throughout
PARA-AMINOHIPPURATE
RENAL
Hg,
and
significantly
increase
(mean
4).
h (range,
increased
dynes.scm5
(106.5
Hg)
were
significantly
when
compared
of44
resistance
790 130
crO
0.94
pressure
mm
dynes#{149}s.cm5)
initial
evaluation
1000
FIGURE
blood
(71.93.6
1400
zE
of
Systolic
MAP
Results
hemodynamics
serial
namic
state
at the
The initial
CI was
measurements
I,
PAH
in the
revealed
six septic
pa-
EXTRACTION
COEFFICIENT
a hyperdy-
time
of the initial
measurements.
elevated
(mean,
5.5 0.43 L/min/
174
III (Brenner
eta!)
12 determinations
in six patients;
blood
flow
at the time
of 112
to
1,767
mI/min
mm) by corrected
up evaluation,
after
CPAH.
patients
to a mean
of 737
4,E]).
Renal
15,600
did
not
5,822
systemic
hemodynamic
at the
Renal
blood
flow
There
dosage
179
p>O.2O).
directly
with
(CI,
also
was
no
did
SVR
not
any
or arterial
The
change
to the kidneys
(RBF/
(Fig 4,H [p<O.O5fl.
correlate
correlation
with
between
kidneys
in any of these
or changes
pressor
during
Glomerular
filtration
four
was
ofseven
reduced
septic
rate
patients.
(range,
18 to 126 mI/mm).
significantly
(0.36 mg/dL
the
first
24 h of shock
filtration
(r =
Initial
Serum
by
<60
GFR
inulin
mI/mm)
varied
in
in these
levels rose
p = 0.012)
within
patients.
of total
blood
flow
r = 0.92,
p = 0.003
Glomerular
filtration
rate
determinations.
did
not
change
going
[Fig
the feasibility
in critically
to
7]).
signfficantly
the
Gbon
a variety
confirm
accurate
including
vein
need
for renal
catheters
unit.
reducdue to
with
renal
Our results
are
PAH kinetics
catheterization
of RBF;
for these
PAH
strong
correlation
p<O.05)
across
patients
Renal
(112 to
hemodynamics
in
the
RBF among
found
decreases
in significant
lution-determined
for
extractions
was
found
RBF
and
wide
range
1,767
in PAH
errors
in the
thermodi-
methods
ofbbood
extrac-
estimation
between
CPAH
(r = 0.79,
flows
in these
mI/mm
blood
flow; [Fig 5]).
demonstrated
large
variability
patients
with
sepsis,
by previous
12,
similar
to results
No direct
correla-
flow
between
vascular
resistance
the
oftotal
going
to the
initial
and
index
did
study
findings
and
suggest
occurring
The overall
for the patients
documents
vein
care
interference
the
ring to a corresponding
It is unknown
whether
priate
renal vascular
and
variable
patients
flow817
ofaltered
result
vasodilation
0
study
shunting
ofbbood
with observations
to account
tion would
of RBF.
throughout
LU
This
CPAH
ranged
from 28 to 90 percent
in our patients
(mean,
55.7 5.6 percent;
normal
values
exceed
90 percent).
These
rr
that
The
indwelling
renal
in the intensive
determination
as systemic
vascular
RBF.
of causes
catheter
ill patients.
of using
ill patients
significantly
vein
critically
PAH secretion
secondary
to tubular
dysfunction,
competition
for anionic
secretory
sites by drugs,
interference
of assay measurements
by various
medications,
fraction
LU
renal
and
Previous
investigators
have found
tions in renal PAH extraction
in septic
creatinine
increase,
in septic
catheter
can determine
bevels (with extraction
widely
with
the fraction
kidneys
(RBF/CO;
follow-up
GFR,
rate
0.505;
merular
determined
(initial
developed
RBF
Failure
recovery.
clearance
measures
and
dopammne
parameters
have
and possibly
in agreement
or levophed
dosage
and initial
RBF, follow-up
value,
percentage
of blood
flow going
to the
RBF
We
thermodilution-derived
[Fig
of follow-up
evaluation.
flow going
of follow-up
mI/
on followin septic
(p<O.O5
time
correlate
of initial
DISCussIoN
averaged
evaluation
and
dynes.s.cm,
not
parameter
time
in the fraction
ofblood
CO)
rose at the time
dosage.
mL/min
at the
3,365
did
percent
among
with a
690
resistance
on initial
significantly
(11,050
blood
flow
pressure)
(mean,
168
dynes.s.cm
evaluation
Renal
>90
Renal
blood
flow
24 to 72 h, increased
vascular
change
normal,
varied
considerably
of initial
evaluation
blood
increased
not change
did
not
that
the
in septic
increased
measurements,
(p<O.05).
Renal
significantly
correlate
with
profound
patients
SVR.
systemic
is not
occur-
degree
in the renal vasculature.
these findings
represent
approregulatory
functions.
adequacy
in our
flow
kidneys
final
going
of RBF is difficult
to assess
study.
The rise in the fraction
to the
kidneys
during
recovery
from
sepsis
suggests
that
the
vasodilation
in the
systemic
circulation
during
the initial
phase
of the
septic episode
was not matched
in the renal circulation.
10
RBF/CO
FIGURE
7. Correlation
to the kidneys
with
correlation
coefficient
20
these
total blood
flow
phase
of sepsis.
(%)
ofthe
initial fraction
oftotal
blood
GFR (by inulin
clearance)
in septic
of0.92
was obtained
(p=0.003).
As a result,
flow going
patients.
A
dilation
blood
occurred
patients
had
fraction
of their
in a higher
fraction
acute
vaso-
of renal
flow
CHEST
a lower
I 98 I I I JULY, 1990
175
This study
interventions
to assess
function.
the effects
Additionally,
of
Previous
investigations
atinine
clearance
have
shown
measurements
that
are
standard
cre-
insensitive
meas-
ures ofthe
GFR in mild renal dysfunction
and become
progressively
less accurate
with decreasing
GFR.2
In this study,
GFR
determined
by inulin
clearance
agent
adjustments
used
in
according
to systemic
blood
While
no correlation
between
correlated
closely
with the fraction
going
to the kidneys
(RBF/CO),
was
seen,
this
cannot
pressor.related
RBF techniques
which
be
effects
The correlation
thermodilution
could
as evidence
against
was strong
between
RBF
measurements
clearance
methods.
is similar
to regression
catheter
models.
Thermo-
been
These
modilution
RBF
methods
A disadvantage
is that
from
This
was
the
the
can
of the
thermistor
cold
bolus
information
thermodilution
must
injectate
be
completely
before
is accomplished
designed
provide
it
by using
the
that
injectate
to assure
exits
in
to 3 cm
injectate
must
thermistor
must
lay
vein,
a maximum
distance
can separate
solution
with
take
place
them
blood
within
average
rates
limits
for the
of RBF
accuracy
tion methods,
RBF in these
there was
patients.
The
study
Complete
flowing
this
approach
of bolus
use of standard
is not optimal
a strong
natively,
the
be
which
and
of the
a direct
progressive
RBFs
of greater
renal
than
mu
900
relationship
constriction,
between
(2) relative
caused
renal
renal
tissue
(3) induction
blood
to the
afferent
and
inadequacy
flow
insertion
abnormalities
of the
dysfunction
that
are
that
catheter.
in these
by mechanisms
metabolic
of renal
Alter-
patients
unrelated
may
to total
Previous
blood
flow
reports
of renal
vein
determination
reveal
complications
from
cannulation.9b0,
reports
ofrenal
procedures
involving
We have
catheters
vein
catheterization
a low incidence
apparent
studied.
and
the
when
Excursion
not found
remaining
a larger
ofthe
body motion
inferior
vena
renal
series
veins
of
renal
vein
any previous
in situ for up
and
experienced
may become
of patients
during
caused
the catheter
cava in some patients.
is
respiration
to migrate
into
The catheter
correlation
emphasizes
the need
to serially
evaluate
the catheter
position
using abdominal
radiographs
and characteristic renal vein thermodilution
curves.
In conclusion,
we have found
that renal vein catheterization
can be performed
safely
in the intensive
bolus
CO
for RBF
the
was
a reflection
rather
than
RBF.
cath-
the
vasodiGFR
had to be replaced
over a guidewire
for some
follow-up
RBF determinations
in five patients.
in the critically
ill.
techniques
(including
and software
optimized
may further
improve
Inulin
clearance
Although
be
sepsis
developed
by transient
catheter.
completely
of only
then
insulated
the
non-renal
decreased
the theoretic
lower
injectate
thermodilu-
accuracy.
used
to
with
PAH
equipment
in this
ranges.
The
close
correlation
between
thermodilution
shows
promise
for instantaneous
serial
measurements
tions of these
tion methods,
of blood
demands
prior
mixing
of the
in the renal vein
distance.
in the
arteriolar
dysfunction
eter at a point
most proximal
in the renal
vein, then
passes
the thermistor
on the distal
tip of the catheter
on the way to the inferior
vena cava (Fig 3).221
The
pigtail
catheter
can generally
be inserted
only 2 to 3
cm into the renal
vein.
Since
both the injectate
port
and
the
detector
within
the renal
repeated
occurred
shape
leaves
failure
method
the
pigtail
ischemia.
patient
despite
profound
between
result
of renal
One
septic
alteration
efferent
on
flow
RBF.
mm. Thus,
renal
dysfunction
in septic
patients
may
occur
in the absence
of detectable
absolute
decreases
in RBF.
Pathophysiobogically,
this may represent:
(1)
shown
to be valid
in most
padata suggest
that the use of ther-
rapid,
serial
changes
critically
ill patients
of more
correlation
RBF
might
of the underlying
severity
kidneys,
vessels
ovarian,
I#{176}--
a marker
The
fractional
RBF determination
by this method
assumes
renal vein is present
on the side of measurethat
equal
blood
flow
is occurring
to both
tions
be
lation.
dilution
a single
ment,
blood
total
for increased
renal demands.
Alternatively,
the
fraction
of blood
flow to the renal
circulation
may
(and slope)
previously
of total
but not
instantaneous
and continuous
This correlation
equations
reported
RBF
injectate
by
be investigated.
CPAH
bolus
taken
effects.
Instantaneous
thermodilution
may represent
an excellent
means
such
with
this
study
were
made
pressure
parameters.
pressor
doses and RBF
RBF
and
thermodilution
CPA)1
Future
modificacontinuous
injecin RBF ranges)
care
were
176
GFR.
environment
complications
catheterization
required
due
determine
unit
no
to
extraction
Renal
on critically
ill patients.
There
in our patients.
Renal
vein
direct
renal
determination
and
for
accurate
variable
of PAH
Blood
Flow
of the
This
and
significantly
in septic
Abnormalities
patients.
in Septic
blood
sampling
of RBF by
decreased
In our
and Critically
are
CPAH
renal
septic
III (Brenner
and
et a!)
critically
ill patients,
modilution
RBF
the
percutaneously
catheter
proved
to be
placed
ther-
accurate
and
can remain
intravascularly
to allow serial instantaneous
measurements
during
a period
of several
days. This
study
demonstrates
the potential
utility
of RBF catheters
in defining
the
pathophysiology
tion in septic
patients.
be useful
in evaluating
tions
RBF
on
ofrenal
dysfunc-
Renal
vein catheters
the effects
ofvarious
and
renal
function
also may
interven-
in
critically
ill
patients.
ACKNOWLEDGMENTS:
We would
like to thank
Ms. Debbie
Tribett
and the 1OD-ICU
nursing
staff for their
help and support
with this project.
We would
also like to thank Mrs. Julie Jordan,
Mr.
Gary
Morrison
and the technical
staff of 1OD for their technical
assistance
and advice.
The
for the
the
computation
relationship
constant
between
thermodilution
is the conversion
the integrated
area
temperature
curve
and
factor
under
the
actual
flow
rate
of the
Manual:
A Guide
fluid
(Hewlett-Packard
Reference
to Hemodynamic
Monitoring
Using
the
Swan-Ganz
Warmed
fluid
Catheter,
pumped
was
Hewlett-Packard
through
the tubing
in Figure
1 and collected
volumetrically.
vitro) were determined
as follows:
the
catheter
against
pump
Corp,
New
diameter
tubing
was
Thermodilution
CO
Packard
Co).
Co).
shown
The CC
thermodilution
(in
was introduced
30 cm upstream
in the tubing
a flow of water
produced
by a variable
rotary
(Varistaltic
Pump,
A series
model
72-325-000,
Monostat
ternal
Using
indicator
minute)
York).
thermally
used
in
outputs
computer
Fourteen-millimeter
insulated
all
of
dilution
technique,#{176}
was determined
as:
volume
output
was
(model
for
studies
(1,
calculated
as:is
then
each
1.5
injectate
and
3 ml)
by
IL).
All
injectates
in
range
the
from
room
was
used
130
this
was
with
range.
main-
dependent
(21.6#{176}to
on the
computer
for low
to 350
5 percent
temperature
Hewlett-Packard
VI of 1 ml was
ments
performed
at
VI used
using
varied
from
130 to
flow
measurements
with concurrent
volu-
39.7#{176}Cusing a heated
water
Scientific
Group,
Chicago,
were
water
24.2#{176}C).The
CC/(60)VI.
at intervals
within
perfusate
water
bath
36.1 and
Precision
25,
dextrose
flow
rate
mL/min.
flow
range
A VI
rate
system.
measure-
of 1.5
ml
was
employed
for all measurements.
Five therflow measurements
were obtained
at each
Thermodilution
curves
were
generated
for
thermodilution
to
output
ensure
(model
proper
R-302P:
using
a two-channel
positioning
Lexington
re-
and
injection
Instruments,
MA).
Taking
per
then
between
bath
Waltham,
liters
(TB-TI)
determined
our
metric
measurements
Temperature
of the
on a Hewlett-
(in
(in vitro)
1.foTB(T)dt
CC
were
in
Rotameter
2,700
mI/mm.
were
obtained
corder
technique
Stewart-Hamilton
presetting
the rotameter
volumetrically
to a known
rate and adjusting
the in vitro
thermodilution
CC to
obtain
the correct
flow rate. The CT for each injectate
C, Hewlett-Packard
the
CCs
used
rubber
measurements.
measured
(HP-78231
a modification
in-
Silicon
calibration
were
Thermal
volume
tamed
APPENDIX
utpu
into
and specific
the CC used
difference
in specific
heat
gravity
between
blood,
in vitro were calculated
account
the
water,
and
as:#{176}-3
D5W,
CC (in vivo)=(1.08)CT(60)VI
density
ii)
Thermodllutlon
Computer
wIth
Recorder
(D5W
1 08 = specific density
heat
In
Thermodllutl
CatheterVein
Renal
the
(
Variable
Rate FluId
Pump
this
case
adjusted
VI.
the
the
Consequently,
dilution
RBF and
ear.
Thus,
CCs
Fluid
Device
Appendix
FIGURE
1. This
figure
depicts
the system
used
for in
vitro
standardization
of the RBF catheter.
Computation
constants
relating
the area under
the thermodilution
flow curve
to the fluid
flow rate were
determined
and the accuracy
of the catheter
was
validated
by comparing
known
flow rates measured
volumetrically
to rates obtained
by the thermodilution
catheter.
constant
volumetric
and
the
by
thermo-
measurements
VIs have
been
is nonlinadjusted
and low
constants
flow ranges
for
CO computer
system
to be 0.037
determined
been
added
between
has
of flow
relation
this catheter
monitoring
for flow
VI of 1.0
ml,
RBF
rate
was
found
CHEST
(blood)
component
the
accordingly
at high
The computation
Volumetric
Collecting
heat
computation
to subtract
(D5W
(blood) or x water)
specific
or water)
I 98
to be above
I 1 I JULY, 1990
1,500
177
mI/min,
the
priate
CC
was
VI
increased
Similarly,
selected.
mi/min
with
creased
to 1.0
the
to 3 ml and
for flow rates
sample,
initial
ml with
the approbelow
350
injectates
selection
ofthe
were
ratories
Pathology
The inulin
assay
de-
bowed
corresponding
by
assay
indoleacetic
variance
in 19 separate
injections)
in the eight
patients
measurements
was 0.014.
Average
total
(95
PAH
Clearance
An
continuous
infusion
fully
drained
of
PAH
calculated
was
followed
to obtain
a serum
period,
were
by
an
indwelling
Foley
solution
and air irrigations
of the bladder
performed
ifurine
output
was less than 60 mI/h
collection
period.
samples
were
each collection
each
PAH
sample
obtained
period.
(Fig
clearance
X
UPAH
were
and
= U
corrected
tation
veloped
were
during
of
in
VPAH/(ArtPAH)
inulin
clearances
were
milliliter,
and V1 is measured
Para-aminohippurate
and
formed
Nuys,
of
from
was
absorbance
in
iso-amyl
the
with
obtained
as
V1,,/Art1,,.
in milligrams
of
the
methoxazole
concentration,
serum
and
before
Mpert
JS,
Little
Brown
3 Sladen
FN.
Dalen
Laboratories
University
(Van
Labo-
Ayres
MD:
JE.
4 Werb
nosis
Acute
SM.
renal
care
failure
Major
issues
AL.
renal
N.
septic
in critically
care
Aetiology,
failure
j5.
JD,
Schrier
BL,
RW
Stein
Little
JH.
In:
care
Baltimore,
2
(L/min)
of thermodilution
catheflow rates.
A correlation
p<O.OOl.
178
The
New
treatment
A,
outflow
Renal
prog-
Resuscitation
1971;
HL.
renal
circulation.
621-33,
Lucas
CE,
Donath
HJ.
V. The
in health
function
Press,
University
the
Priebe
in anesthesiology.
measurement
of the
renal
method.
therrnodilution
local
and
1951
venography.
Brown
and
In: Abrams
HL.
Co, 1983;
1327-63
kidney.
Philadelphia:
FC.
The
FE,
Werner
M,
sepsis.
Arch
Angiography.
WB
Saunders,
308-09
Rector
with acute
A.
glomerular
single
In:
renal
22:35-63
and
structure
by
acute
8:17-32
B, Rector
1981;
1984;
of
30:193-200
in
kidney
man
Renal
Little,
Brenner
1982;
hemodynamics
The
Oxford
in
the importance
198(Ys:
42:603-14
J, Slechta
Bred
homeostasis
13
Parrillo
and
unit.
Nephron
1980;
kidney:
York:
venous
12
medicine.
care
in the
and Co,
Brown
HW.
Boston:
MA:
results
ill patients:
diagnosis,
renal
failure
and ofendotoxaemia.
9 Hornych
11
Boston
environment.
in an intensive
10 Abrams
with
PAH
1984:215-19
Acute
shock
Nephron
of0.997
absorb-
to the
7:95-100
5 Wardle
disease.
Flow
residual
medicine.
in Critical
and Wifldns,
R, Linton
Boston:
comparison
volumetric
a slope of 1.02,
iso-
sulfa-
1985:481-907
in an intensive
ofacute
1979;
Intensive
and Co.
Williams
8 Smith
Volumetric
after
the
REFERENCES
JE,
In vitro
against
samples
to
the
deof
difference
and
is proportional
Internationalanesthesiologycinics-the
2.
flows
urine
The
and
extraction
precipi-
1 Gardner
P, Arnow
PM.
Hospital-acquired
infections.
In: Harrison T, et al, eds. Harrison
principles
ofinternal medicine. New
York: McGraw-Hill
Book Co mc, 1987:470
2 Schuster
DP, Lefrak
55. Septic
shock.
In: Bippe
JM, Irwin ES,
6 Conger
failure.
7 Margolis
FIGURE
for
recently
removal
is proportional
extraction
following
acetate
using
involved
samples
amylacetate
per
Appendix
ter.determined
coefficient
developed
iso-amylacetate.
per milliliter
milliliters
per
in milliliters
per minute.
inulin
assays
were
per-
CA).
the stan-
with
interferes
a method
following
of management
by the Smith-Kline
French
CA) and by the Georgetown
and
Nuys,
concentration.
of 50 mg/kg
was
calculated
to attain
x
Van
the
sulfamethoxazole
methods.
This
assay
by precipitation
ance
Clearance
Standard
Para-aminohippurate
method,
sulfamethoxazole
urine
VPAI/(ArtPAff-VenPAH)
in milligrams
is measured
in
measure
of GFR.
Bolus
injection
followed
by constant
inulin infusion
serum
levels of 10 to 20 mg/dl.
Inulin
Clearance
= U1,
The U1,, and Art1,, were
measured
to form the
(Smith
Kline
Laboratories,
sulfamethoxazole
and
minute.
Inulin
Bratforma-
salt
two
care-
and end
measured
measured
which
PAH,
arterial
at the beginning
PAH bevels were
(uncorrected)
PAH
except
vein,
the
diazonium
sulfamethoxazole
assay
PAH
colorimetric
utilized
assaying
PAH
levels
in patients
receiving
sulfamethoxazole/trimethoprim
Para-aminohippurate
levels
were
determined
in two patients
on trimethoprim-
2).
clearance
All values
ReIiaI
level
catheter
saline
the
by
dard
for
assay
involving
Kline
Preuss,
M.D.).
hydrolysis
fol-
reaction
PAH
Manual:
Smith
Because
bolus
of 1 to 2 mg/dl.
30-min
collections
reaction
Procedure
Inulin,
Method
mg/kg
The
tion followed
by coupling
assayed
colorimetrically
istry
APPENDIX
acid
quantification.
ton-Marshal
CC.
Department
(H.G.
utilized
acidification
The
simultaneous
filtration
rate
injection
and
clearance
Rosenberg
Surg
1K. Altered
1973;
determination
effective
technique.
renal
Acts
renal
106:444-49
in
children
plasma
flow
Paediat
Scand
of
by the
1971;
60:512-20
Renal
Blood
Flow
AbnormalIties
in Septic
and Critically
III (Brenner
at a!)
14
Aukland
and
15
K. Methods
for measuring
renal
Ann
Physiol
distribution.
regional
Rev
blood
flow:
1980;
total
flow
42:543-55
BR,
priate
24
Giangiacomo
of
25
JA,
Gagnon
17
Sykes
BJ,
18
Rosenberg
19
Duarte
J, Schenk
Obstet
135:877-82
1K,
Gupta
CG,
and
20
Liedtke
F, Guo-Quing
L.
Cardiovasc
22
23
1982;
F, Tarazi
ofpigtail
26
into
blood
the
27
flow.
Pitts
FF.
Book
Lucas
CE,
Khan
AA.
filtration
rate
tests.
insuffi-
28
193:175:83
38:495-99
WH,
RC.
A critical
for measuring
New
J,
of the
Publishers
Lucas
EE,
Biggs
in normal
McIntyre
KM.
Lewis
support.
American
Kim
Onesti
EK,
I.
disease:
112:471-76
Lab
Invest
function
in the
and excretion
J Cliii
Textbook
of renal
Clin
Invest
1959;
of advanced
Association,
G, Ramirez
1977;
Scand
subjects.
JA.
Heart
in renal
and
Boston:
Berlyne
of
389-94
life
cardiac
1987:XIII-5
0, Breast
Swartz
AN,
a reappraisal.
Br
C. Creatinine
Med
1969;
4:11-
GM,
renal
plasma
Little
Brown
improvement
29
Sato
renal
blood
flow
approach
basic
to local
surgery.
in man.
30 Fronek
Cardiovasc
kidney
mc,
Gerrick
and
body
fluids.
Res
Chicago:
H,
Eguchi
dobutamine
and
renal
Japan
Circ
of inappro-
A, Ganz
S. Comparative
and
dopamine
V. Measurement
cardiac
output
Lancet
study
of
on systemic
following
of flow
by local
in single
1964;
effects
hemodyopen
blood
heart
vessels
thermodilution.
31
Ganz
32
Preuss
W, Swan
Am
JH.
Cardiol
HG,
Razavi
Chem
1988;
Measurement
of blood
1972;
29:241-46
MH,
Slemmer
in
the
presence
D,
Zein
of
flow
M.
by thermodiluColorimetry
sulfamethoxazole.
of
Clin
34:422-23
CHEST
M. Endogenous
rate.
p-aminohippurate
1974:140-57
SJ. Mechanism
H, Hoerni
8:175-182
thermodilution:
difficulties.
S, Varley
and glomerular.filtration
Y, Matsuzawa
of adrenaline,
local
of the
Nilwarangkur
clearance
11:874-79
for
tion.
Medical
DS,
water
Surg
S. Determination
method.
of man:
solute and
including
to avoid
Physiology
Baldwin
kidneys
creatinme
and methods
protocols
function
Renal
1971;
16:359-54
catheters
A, Zito
1978;
Arch
Simonson
by thermodilution
clearance
11:576-80
Year
Cortez
study
renal
flow
namics
method
Bes
Magrini
1977;
experimental
renal
22:29-40
1980:49-65
Magrini
use
An
1978;
blood
Hulet
patients.
EK,
14
glomenilar
Renal
Pyrogenic
of measuring
Laboratory
CG.
thermodilution
21
RB.
of
In: Duarte
Co,
SL,
W.
Nephron
trauma
the measurement
flow.
WG.
methods
after
Flamenbaum
ofprostaglandins.
clearance
Gynec
ciency
PW,
role
Hoie
of
validity
Surg
Ramwell
the
hyperemia:
in septic
T, Brodwall
separate
14
16
polyuria
Leivestad
I 98 I 1 I JULY, 1990
179