Diagnostic Adjunct Techniques in the Assessment of Hypovolemia: A Prospective Pilot Project.

INTRODUCTION: Measuring the hypovolemic resuscitation end point remains a critical care challenge. Our project compared clinical hypovolemia (CH) with three diagnostic adjuncts: 1) noninvasive cardiac output monitoring (NICOM), 2) ultrasound (US) static IVC collapsibility (US-IVC), and 3) US dynamic carotid upstroke velocity (US-C). We hypothesized US measures would correlate more closely to CH than NICOM. METHODS: Adult trauma/surgical intensive care unit patients were prospectively screened for suspected hypovolemia after acute resuscitation, excluding patients with burns, known heart failure, or severe liver/kidney disease. Adjunct measurements were assessed up to twice a day until clinical improvement. Hypovolemia was defined as: 1) NICOM: ≥10% stroke volume variation with passive leg raise, 2) US-IVC: <2.1 cm and >50% collapsibility (nonventilated) or >18% collapsibility (ventilated), 3) US-C: peak systolic velocity increase 15 cm/s with passive leg raise. Previously unknown cardiac dysfunction seen on US was noted. Observation-level data were analyzed with a Cohen's kappa (κ). RESULTS: 44 patients (62% male, median age 60) yielded 65 measures. Positive agreement with CH was 47% for NICOM, 37% for US-IVC and 10% for US-C. None of the three adjuncts correlated with CH (κ -0.045 to 0.029). After adjusting for previously unknown cardiac dysfunction present in 10 patients, no adjuncts correlated with CH (κ -0.036 to 0.031). No technique correlated with any other (κ -0.118 to 0.083). CONCLUSIONS: None of the adjunct measurements correlated with CH or each other, highlighting that fluid status assessment remains challenging in critical care. US should assess for right ventricular dysfunction prior to resuscitation.

Use of POCUS for the assessment of dehydration in pediatric patients-a narrative review.

In pediatric practice, POCUS (point-of-care ultrasound) has been mostly implemented to recognize lung conditions and pleural and pericardial effusions, but less to evaluate fluid depletion. The main aim of this review is to analyze the current literature on the assessment of dehydration in pediatric patients by using POCUS. The size of the inferior vena cava (IVC) and its change in diameter in response to respiration have been investigated as a tool to screen for hypovolemia. A dilated IVC with decreased collapsibility (< 50%) is a sign of increased right atrial pressure. On the contrary, a collapsed IVC may be indicative of hypovolemia. The IVC collapsibility index (cIVC) reflects the decrease in the diameter upon inspiration. Altogether the IVC diameter and collapsibility index can be easily determined, but their role in children has not been fully demonstrated, and an estimation of volume status solely by assessing the IVC should thus be interpreted with caution. The inferior vena cava/abdominal aorta (IVC/AO) ratio may be a suitable parameter to assess the volume status in pediatric patients even though there is a need to define age-based thresholds. A combination of vascular, lung, and cardiac POCUS could be a valuable supplementary tool in the assessment of dehydration in several clinical scenarios, enabling rapid identification of life-threatening primary etiologies and helping physicians avoid inappropriate therapeutic interventions.   Conclusion: POCUS can provide important information in the assessment of intravascular fluid status in emergency scenarios, but measurements may be confounded by a number of other clinical variables. The inclusion of lung and cardiac views may assist in better understanding the patient's physiology and etiology regarding volume status. What is Known: • In pediatric practice, POCUS (point-of-care ultrasound) has been mostly implemented to recognize lung conditions (like pneumonia and bronchiolitis) and pleural and pericardial effusions, but less to evaluate fluid depletion. • The size of the IVC (inferior vena cava) and its change in diameter in response to respiration have been studied as a possible screening tool to assess the volume status, predict fluid responsiveness, and assess potential intolerance to fluid loading. What is New: • The IVC diameter and collapsibility index can be easily assessed, but their role in predicting dehydration in pediatric age has not been fully demonstrated, and an estimation of volume status only by assessing the IVC should be interpreted carefully. • The IVC /AO(inferior vena cava/abdominal aorta) ratio may be a suitable parameter to assess the volume status in pediatric patients even though there is a need to define age-based thresholds. A combination of vascular, lung, and cardiac POCUS can be a valuable supplementary tool in the assessment of intravascular volume in several clinical scenarios.

Phlebotomy resulting in controlled hypovolemia to prevent blood loss in major hepatic resections (PRICE-2): study protocol for a phase 3 randomized controlled trial.

INTRODUCTION: Blood loss and red blood cell (RBC) transfusion in liver surgery are areas of concern for surgeons, anesthesiologists, and patients alike. While various methods are employed to reduce surgical blood loss, the evidence base surrounding each intervention is limited. Hypovolemic phlebotomy, the removal of whole blood from the patient without volume replacement during liver transection, has been strongly associated with decreased bleeding and RBC transfusion in observational studies. This trial aims to investigate whether hypovolemic phlebotomy is superior to usual care in reducing RBC transfusions in liver resection. METHODS: This study is a double-blind multicenter randomized controlled trial. Adult patients undergoing major hepatic resections for any indication will be randomly allocated in a 1:1 ratio to either hypovolemic phlebotomy and usual care or usual care alone. Exclusion criteria will be minor resections, preoperative hemoglobin <100g/L, renal insufficiency, and other contraindication to hypovolemic phlebotomy. The primary outcome will be the proportion of patients receiving at least one allogeneic RBC transfusion unit within 30 days of the onset of surgery. Secondary outcomes will include transfusion of other allogeneic blood products, blood loss, morbidity, mortality, and intraoperative physiologic parameters. The surgical team will be blinded to the intervention. Randomization will occur on the morning of surgery. The sample size will comprise 440 patients. Enrolment will occur at four Canadian academic liver surgery centers over a 4-year period. Ethics approval will be obtained at participating sites before enrolment. DISCUSSION: The results of this randomized control trial will provide high-quality evidence regarding the use of hypovolemic phlebotomy in major liver resection and its effects on RBC transfusion. If proven to be effective, this intervention could become standard of care in liver operations internationally and become incorporated within perioperative patient blood management programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT03651154 . Registered on August 29 2018.

Assessment of Intravascular Volume Status in Children with Nephrotic Edema Using Serum and Urinary Indices and Its Correlation with Inferior Vena Cava Collapsibility Index.

Identification of volume status in nephrotic syndrome (NS) is important but clinically challenging. Urinary and serum indices can be helpful in assessing the volume status and so can be inferior vena cava collapsibility index (IVCCI). This study was done to assess the serum and urinary indices in children with nephrotic edema and to correlate them with IVCCI for intravascular volume assessment. Fifty children with nephrotic edema and 47 children in remission were analyzed for blood and urine indices. Volume status was defined as overfilling or underfilling based on the biochemical indices and also by IVCCI. Eighty-four percent individuals among cases and 23% among controls had sodium retention (FENa < 0.5%). Among cases, 54% had primary sodium retention compared to 17% among controls (p = 0.0002). Hypovolemia was observed among 36% cases based on biochemical indices and in 20% cases as per IVCCI. Hypovolemia was significantly associated with low urinary sodium and low serum albumin.

The role of bioelectrical impedance analysis, NT-ProBNP and inferior vena cava sonography in the assessment of body fluid volume in children with nephrotic syndrome.

BACKGROUND: Assessment of volume status and differentiating "underfill" and "overfill" edema is essential in the management of patients with nephrotic syndrome (NS). OBJECTIVES: Our aim was to evaluate the volume status of NS patients by using different methods and to investigate the utility of bioelectrical impedance analysis (BIA) in children with NS. METHODS: The hydration status of 19 patients with NS (before treatment of NS and at remission) and 25 healthy controls was assessed by multifrequency BIA, serum N-terminal-pro-brain natriuretic peptide (NT-proBNP) levels, inferior vena cava (IVC) diameter, left atrium diameter (LAD) and vasoactive hormones. RESULTS: Renin, aldosterone levels, IVC diameter and LAD were not statistically different between the groups. NT-proBNP values were statistically higher in the attack period compared to remission and the control group (p=0.005 for each). Total body water (TBW), overhydration (OH) and extracellular water (ECW) estimated by the BIA measurement in the attack group was significantly higher than that of the remission group and controls. There were no significant correlations among volume indicators in group I and group II. However, significant correlations were observed between NT-proBNP and TBW/BSA (p=0.008), ECW/BSA (p=0.003) and ECW/ICW (p=0.023) in the healthy group. TBW was found to be higher in patients with NS in association with increased ECW but without any change in ICW. NT-proBNP values were higher in patients during acute attack than during remission. CONCLUSIONS: Our findings support the lack of hypovolaemia in NS during acute attack. In addition, BIA is an easy-to-perform method for use in routine clinical practice to determine hydration status in patients with NS.

Assessment of hypovolaemia in the critically ill.

Assessment of the intravascular volume status of patients is one of the most challenging tasks for the intensive care clinician. It is also one of the most important skills in intensive care management as both hypervolaemia and hypovolaemia lead to increased morbidity and mortality. The assessment of hypovolaemic patients is aided by several clinical signs, laboratory investigations, and a multitude of haemodynamic monitoring systems. This review aims to outline the definitions, pathophysiology, and various assessment techniques (both old and new) employed by intensivists on the critically ill patient.

Assessment of Volume Status Using Ultrasonography.

Ultrasonography is a first-line diagnostic tool when evaluating volume status in the critical care patient population. Ultrasonography leads to a prompt diagnosis and more appropriate management plan, while decreasing health care costs, time to diagnosis, hospital length of stay, time to definitive operation, and mortality. It is recommended that critical care providers treating critically ill patients be skilled and competent in critical care ultrasonography. As the critical care population and the shortage of critical care physicians increases, advanced practice providers are becoming more prevalent in critical care areas and should be competent in this skill as well.

Practical Assessment of Volume Status in Daily Practice.

Fluid therapy is considered the cornerstone of treatment for patients suffering from various medical ailments particularly in emergency and critical care situations where hypovolemia commonly occurs. The ability to accurately assess a patient's volume status is critical to the decision making process when synthesizing and implementing a fluid therapy plan. Both extremes, over supplementation or not supplementing enough fluid can be detrimental to the patient. Precisely assessing a patient's blood volume without access to advanced often complicated equipment and monitoring devices is challenging. The aim of this paper is to review the practical means and tools available to aide in estimating a patient's volume status.

The efficacy of novel anatomical sites for the assessment of muscle oxygenation during central hypovolemia.

Muscle tissue oxygenation (SmO2) can track central blood volume loss associated with hemorrhage. Traditional peripheral measurement sites (e.g., forearm) may not be practical due to excessive movement or injury (e.g., amputation). The aim of this study was to evaluate the efficacy of three novel anatomical sites for the assessment of SmO2 under progressive central hypovolemia. 10 male volunteers were exposed to stepwise prone lower body negative pressure to decrease central blood volume, while SmO2 was assessed at four sites-the traditional site of the flexor carpi ulnaris (ARM), and three novel sites not previously investigated during lower body negative pressure, the deltoid, latissimus dorsi, and trapezius. SmO2 at the novel sites was compared to the ARM sensor and to stroke volume responses. A reduction in SmO2 was detected by the ARM sensor at the first level of lower body negative pressure (-15 mmHg; P = 0.007), and at -30 (the deltoid), -45 (latissimus dorsi), and -60 mmHg lower body negative pressure (trapezius) at the novel sites (P ≤ 0.04). SmO2 responses at all novel sites were correlated with responses at the ARM (R ≥ 0.89), and tracked the reduction in stroke volume (R ≥ 0.87); the latissimus dorsi site exhibited the strongest linear correlations (R ≥ 0.96). Of the novel sensor sites, the latissimus dorsi exhibited the strongest linear associations with SmO2 at the ARM, and with reductions in central blood volume. These findings have important implications for detection of hemorrhage in austere environments (e.g., combat) when use of a peripheral sensor may not be ideal, and may facilitate incorporation of these sensors into uniforms.

Noninvasive continuous arterial pressure measurements in the assessment of acute, severe central hypovolemia.

UNLABELLED: Acute, severe hypovolemia is a medical emergency. Traditional vital sign parameters allow no optimal triage. High predictive power of finger plethysmography-based stroke volume (SV) and pulse pressure (PP) was recently suggested. To assess the performance of the PP and SV parameters, lower body negative pressure of -40 mmHg, than -60 mmHg - corresponding to moderate and severe central hypovolemia - was applied in 22 healthy males (age 35 ± 7 years). Slow breathing induced fluctuations in the above indices, characterized by stroke volume variability (SVV), and pulse pressure variability (PPV), were assessed. Responses in heart rate (HR) and shock index (SI) were also studied. Discriminative capacity of these parameters was characterized by the area under the ROC (receiver operating characteristic) curves (AUC). RESULTS: In comparison of baseline to severe central hypovolemia SV, PP, HR, and SI showed good discriminating capacity (AUC 99%, 88%, 87%, and 93%, respectively). The discriminating capacity of SVV and PPV was poor (77% and 70%, respectively). In comparison of moderate and severe hypovolemia, the discriminating capacity of the studied parameters was uniformly limited. CONCLUSIONS: Plethysmography-based SV and PP parameters can be used to detect acute severe volume loss. Sensitive parameters discriminating moderate and severe central hypovolemia are still lacking.

Does ultrasonographic measurement of the inferior vena cava diameter correlate with central venous pressure in the assessment of intravascular volume in patients undergoing gastrointestinal surgery?

BACKGROUND: Ultrasonography has been suggested as a useful noninvasive tool for the detection of hypovolemia in critically ill patients. Hypovolemia after preoperative fasting and bowel preparation may compromise hemodynamic function during gastrointestinal surgery. However, there are few data comparing ultrasonographic examination of the inferior vena cava (IVC) diameter with central venous pressure (CVP) measurement in patients undergoing gastrointestinal surgery in the assessment of intravascular volume status. MATERIALS AND METHODS: Forty American Society of Anesthesiologists I-II patients who underwent elective gastrointestinal surgery and 32 healthy volunteers were enrolled in the study. The IVC diameters, both during expiration (IVCe) and inspiration (IVCi), and right ventricle (RV) were measured with ultrasonography in patients both before and after fluid resuscitation. Volunteers were also measured during the time they participated in the study. RESULTS: Forty patients (mean age 51 y; 45% female) and 32 volunteers (mean age 46 y; 44% female) underwent IVC and RV sonographic measurements. The diameters of the IVCe, IVCi, and RV in patients (1.83, 1.34, and 3.23 cm) were significantly lower compared with those of healthy volunteers (1.18, 0.62, and 2.71 cm). After fluid resuscitation, IVCe, IVCi, and RV in hypovolemic patients (1.75, 1.25, and 3.27 cm) significantly increased. The pre-IVCe and the post-IVCe were closely correlated to the CVP (r = 0.585 and r = 0.609, respectively). Similarly, the pre-RV and the post-RV were correlated to the CVP (r = 0.347 and r = 0.439, respectively). CONCLUSIONS: Our data demonstrate that the IVC and RV diameters are consistently low in patients undergoing gastrointestinal surgery when compared with healthy subjects. Ultrasonographic measurements of the IVC and RV diameters are useful supplement of CVP for the evaluation of preoperative patients with hypovolemia.

A sensitive shock index for real-time patient assessment during simulated hemorrhage.

BACKGROUND: Shock index [SI = the ratio of heart rate (HR) to systolic arterial pressure (SAP)] is a metric used to diagnose patients at risk of impending hemorrhagic shock. We hypothesized that a metric called the compensatory reserve index (CRI), derived using computer modeling with continuous feature extraction from arterial waveforms, would provide an earlier indicator of cardiovascular instability than SI during progressive central hypovolemia. METHODS: There were 15 subjects (men = 8; women = 7) who underwent progressive reduction in central blood volume induced by lower body negative pressure (LBNP) until SAP < 90 mmHg. CRI was normalized on a scale of 1 (normovolemia) to 0 (circulatory volume at which instability occurs) and displayed on a colored bar. The times at which the CRI equaled 0.6 (threshold of green to amber) or 0.3 (threshold of amber to red) were compared to a clinical threshold of SI > or = 0.9. RESULTS: A SI > or = 0.9 required 22.4 +/- 6.2 min (95% CI = 19 to 25.8 min). CRI reached 0.6 (amber) at 12.5 +/- 4.9 min (95% CI = 9.8 to 15.3 min) when SI = 0.61 +/- 0.03, and became 0.3 (red) at 20.3 +/- 5.1 min (95% CI = 17.5 to 23.1 min) when SI = 0.81 +/- 1.4. CONCLUSIONS: CRI provided a significantly earlier indicator of impending hemodynamic decompensation than SI > or = 0.9 during progressive LBNP. These results support the notion that the CRI represents an improved 'shock index' as an indicator of impending hemorrhagic shock compared to standard vital signs.

Variable assessment of the circulation in intensive care unit patients with shock.

INTRODUCTION: Circulatory failure is frequent in intensive care unit (ICU) patients and is associated with a high mortality and morbidity. There is no current consensus on which parameters best evaluate circulatory failure, and clinical practice regarding haemodynamic assessment is unknown. This study describes current clinical practice regarding circulatory assessment in ICU patients with shock. MATERIAL AND METHODS: This was a prospective, observational cohort study conducted in a university hospital ICU over a four-month period. Doctors working in the ICU were divided into two groups: trainees and specialists. They registered their circulatory assessments of consecutive patients with shock. The parameters included type of shock, kind of parameters used (markers of hypoperfusion, hypovolaemia and flow), which parameter was considered to be most important and the clinical action taken. RESULTS: A total of 23 doctors performed 210 patient assessments, which was equivalent to a median of eight (interquartile range: 5-14) per doctor. Trainees used six (5-8) parameters compared with five (3-6) parameters per assessment among specialists (p < 0.01). Mean arterial pressure (MAP) was the most frequently assessed parameter (n = 178) and both specialist (in 23% of assessments) and trainees (30%) considered MAP to be the most important parameter. Hypoperfusion markers were assessed in 99% of the cases, and a marker of hypovolaemia was also assessed in 83% (95% confidence interval (CI) 78-88) of these cases. Fluid was the most frequent clinical action taken, and was given after 150 assessments, but a marker of hypovolaemia was not assessed in 13% (95% CI 9-20) of these situations. Trainees assessed heart rate (76% versus 54%; p < 0.01), diastolic (45% versus 28%, p < 0.01) and systolic blood pressure (70% versus 46%; p < 0.01) and central venous oxygen saturation (63% versus 35%; p < 0.01) more frequently than specialists. CONCLUSION: MAP was the most frequently used parameter and fluid the most frequently given treatment by ICU doctors assessing patients with shock. The study indicates that assessment of hypoperfusion leads to the use of a marker of hypovolaemia, but in some cases fluid was given without this assessment. The haemodynamic assessment differed between ICU specialists and trainees. FUNDING: Righospitalet's Research Council supported the study. TRIAL REGISTRATION: not relevant.

An assessment of global end-diastolic volume and extravascular lung water index during one-lung ventilation: is transpulmonary thermodilution usable?

BACKGROUND: The thermodilution curve assessed by transpulmonary thermodilution is the basis for calculation of global end-diastolic volume index (GEDI) and extravascular lung water index (EVLWI). Until now, it was unclear whether the method is affected by 1-lung ventilation. Therefore, aim of our study was to evaluate the impact of 1-lung ventilation on the thermodilution curve and assessment of GEDI and EVLWI. METHODS: In 23 pigs, mean transit time, down slope time, and difference in blood temperature (ΔTb) were assessed by transpulmonary thermodilution. "Gold standard" cardiac output was measured by pulmonary artery flowprobe (PAFP) and used for GEDIPAFP and EVLWIPAFP calculations. Measurements were performed during normovolemia during double-lung ventilation (M1), 15 minutes after 1-lung ventilation (M2) and during hypovolemia (blood withdrawal 20 mL/kg) during double-lung ventilation (M3) and again 15 minutes after 1-lung ventilation (M4). RESULTS: Configuration of the thermodilution curve was significantly affected by 1-lung ventilation demonstrated by an increase in ΔTb and a decrease in mean transit time and down slope time (all P < 0.04) during normovolemia and hypovolemia. GEDIPAFP was lower after 1-lung ventilation during normovolemia (M1: 459.9 ± 67.5 mL/m(2); M2: 397.0 ± 54.8 mL/m(2); P = 0.001) and hypovolemia (M3: 300.6 ± 40.9 mL/m(2); M4: 275.2 ± 37.6 mL/m(2); P = 0.03). EVLWIPAFP also decreased after 1-lung ventilation in normovolemia (M1: 9.0 [7.3, 10.1] mL/kg; M2: 7.4 [5.8, 8.3] mL/kg; P = 0.01) and hypovolemia (M3: 7.4 [6.3, 9.7] mL/kg; M4: 5.8 [5.2, 7.4]) mL/kg; P = 0.0009). CONCLUSION: Configuration of the thermodilution curve and therefore assessment of GEDI and EVLWI are significantly affected by 1-lung ventilation.

Blood pressure measurement for accurate assessment of patient status in emergency medical settings.

Obtaining blood pressure measurements with traditional sphygomanometry that are insensitive and nonspecific can fail to provide an accurate assessment of patient status, particularly in specific clinical scenarios of acute reduction in central blood volume such as hemorrhage or orthostatic testing. This paper provides a review of newly emerging monitoring technologies that are being developed and integrated to improve patient diagnosis by using collection and feature extraction in real time of arterial waveforms by machine-learning algorithms. With assessment of continuous, noninvasively measured arterial waveforms, machine-learning algorithms have been developed with the capability to predict cardiovascular collapse with > 96% accuracy and a correlation of 0.89 between the time of predicted and actual cardiovascular collapse (e.g., shock, syncope) using a human model of progressive central hypovolemia. The resulting capability to obtain earlier predictions of imminent hemodynamic instability has significant implications for effective countermeasure applications by the aeromedical community. The ability to obtain real-time, continuous information about changes in features and patterns of arterial waveforms in addition to standard blood pressure provides for the first time the capability to assess the status of circulatory blood volume of the patient and can be used to diagnose progression toward development of syncope or overt shock, or guide fluid resuscitation.

Assessment of cardiac preload status by pulse pressure variation in patients after anesthesia induction: comparison with central venous pressure and initial distribution volume of glucose.

PURPOSE: Recognition of intraoperative hypovolemia is important for fluid management. Previous studies demonstrated functional preload parameter pulse pressure variation (PPV) could predict volume changes in response to fluid loading and loss. In this study, we examined the correlation between PPV and other two cardiac preload indicators, central venous pressure (CVP) or initial distribution volume of glucose (IDVG), in patients after anesthesia induction. METHODS: In 30 patients undergoing scheduled craniotomy surgery, we compared measurement of PPV (%) using the Ohmeda monitor method to simultaneously measure CVP and IDVG after anesthesia induction through correlation analysis and receiver operating characteristic (ROC) curves. RESULTS: Pulse pressure variation has negative linear correlation with IDVG (r = -0.65, P < 0.01). IDVG values (n = 13) when PPV ≥ 11% showed a significant difference compared with those (n = 17) when PPV < 11% (P < 0.001). The ROC curve showed the best cutoff value of IDVG is 122 ml/kg, equivalent to the threshold of PPV (11%) for predicting fluid responsiveness. However, there is no significant correlation between CVP in normal ranges (4-9 mmHg) and PPV (r = -0.12, P > 0.05). CONCLUSION: As an indicator of cardiac preload, PPV has a negative linear correlation with IDVG in patients after anesthesia induction. It does not correlate well with CVP in the normal range. Our results imply that an individual PPV, not CVP, is equivalent to IDVG in assessing volume status after induction.

Relative plasma volume monitoring during hemodialysis AIDS the assessment of dry weight.

Among hemodialysis patients, the assessment of dry weight remains a matter of clinical judgment because tests to assess dry weight have not been validated. The objective of this study was to evaluate and validate relative plasma volume (RPV) monitoring as a marker of dry weight. We performed RPV monitoring using the Crit-Line monitor at baseline and at 8 weeks in 150 patients participating in the Dry-Weight Reduction in Hypertensive Hemodialysis Patients Trial. The intervention group of 100 patients had dry weight probed, whereas 50 patients served as time controls. RPV slopes were defined as flat when they were less than the median (1.33% per hour) at the baseline visit. Among predominantly (87%) black hemodialysis patients, we found that flat RPV slopes suggest a volume-overloaded state for the following reasons: (1) probing dry weight in these patients led to steeper slopes; (2) those with flatter slopes at baseline had greater weight loss; (3) both baseline RPV slopes and the intensity of weight loss were found to be important for subsequent change in RPV slopes; and, most importantly, (4) RPV slopes predicted the subsequent reduction in interdialytic ambulatory systolic blood pressure. Those with the flattest slopes had the greatest decline in blood pressure on probing dry weight. Both baseline RPV slopes and the change in RPV slopes were important for subsequent changes in ambulatory systolic blood pressure. We conclude that RPV slope monitoring is a valid method to assess dry weight among hypertensive hemodialysis patients.

The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation.

OBJECTIVES: Organ failure worsens outcome in sepsis. The Sequential Organ Failure Assessment (SOFA) score numerically quantifies the number and severity of failed organs. We examined the utility of the SOFA score for assessing outcome of patients with severe sepsis with evidence of hypoperfusion at the time of emergency department (ED) presentation. DESIGN: Prospective observational study. SETTING: Urban, tertiary ED with an annual census of >110,000. PATIENTS: ED patients with severe sepsis with evidence of hypoperfusion. INCLUSION CRITERIA: suspected infection, two or more criteria of systemic inflammation, and either systolic blood pressure <90 mm Hg after a fluid bolus or lactate >or=4 mmol/L. EXCLUSION CRITERIA: age <18 years or need for immediate surgery. INTERVENTIONS: SOFA scores were calculated at ED recognition (T0) and 72 hours after intensive care unit admission (T72). The primary outcome was in-hospital mortality. The area under the receiver operating characteristic curve was used to evaluate the predictive ability of SOFA scores at each time point. The relationship between Delta SOFA (change in SOFA from T0 to T72) was examined for linearity. RESULTS: A total of 248 subjects aged 57 +/- 16 years, 48% men, were enrolled over 2 years. All patients were treated with a standardized quantitative resuscitation protocol; the in-hospital mortality rate was 21%. The mean SOFA score at T0 was 7.1 +/- 3.6 points and at T72 was 7.4 +/- 4.9 points. The area under the receiver operating characteristic curve of SOFA for predicting in-hospital mortality at T0 was 0.75 (95% confidence interval 0.68-0.83) and at T72 was 0.84 (95% confidence interval 0.77-0.90). The Delta SOFA was found to have a positive relationship with in-hospital mortality. CONCLUSIONS: The SOFA score provides potentially valuable prognostic information on in-hospital survival when applied to patients with severe sepsis with evidence of hypoperfusion at the time of ED presentation.