PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber,...

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Blood Volume Analysis Can Distinguish True Anemia from Hemodilution in Critically Ill Trauma Patients PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

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Blood Volume Analysis Can Distinguish True Anemia from Hemodilution in Critically Ill Trauma Patients. PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD. Background. Hemorrhage leading cause of preventable death in trauma victims - PowerPoint PPT Presentation

Transcript of PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber,...

Page 1: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Blood Volume Analysis Can Distinguish True Anemia from Hemodilution in

Critically Ill Trauma Patients

PY Van, MD SD Cho, MD SJ Underwood, MS ∙ ∙GJ Hamilton, BS LB Ham, MD MA Schreiber, MD∙ ∙

Page 2: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Background

• Hemorrhage leading cause of preventable death in trauma victims

• Decreased peripheral hematocrit (pHct) used as marker for blood loss

• pHct may not represent true red blood cell volume (RBCV)

Page 3: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Background

Page 4: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Background

• Surrogate measures to deduce volume status– Vital signs and physical exam– Laboratory tests– Invasive monitoring

• Experienced clinicians frequently wrong– 51% concordance with blood volume analysis

Androne, AS et al. Am J Cardiol 2004

Page 5: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Blood Volume Analysis

• Indicator dilution principle– Known quantity of tracer injected into unknown

volume (intravascular space)– After equilibration of tracer, plasma sampled

• Concentration of tracer in sample is measured• Unknown volume is inversely proportional to

concentration of tracer in the sample volume• Larger the unknown volume, more dilute the tracer

Page 6: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Concentration of tracer injected

Volume of sample withdrawnConc. tracer in sample withdrawnUnknown volume (plasma volume)

Indicator Dilution Principle

C1

V1

C2

V2

=

Page 7: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Blood Volume Analysis

• Single injection radiolabeled 131I-albumin.• Serial blood samples drawn over 40 minutes• Analysis yields actual and ideal TBV, RBCV, PV

Page 8: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Blood Volume Analysis

pHct

RBCV

RBCV=

+ PV

TBV = RBCV + PV

Page 9: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Blood Volume Analysis

• Normalized hematocrit (nHct)– pHct is adjusted for volume derangement:

nHct = pHct xMeasured TBV

Ideal TBV

Page 10: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Hypothesis

Use of pHct alone in critically ill trauma patients will result in over-diagnosis of anemia

Page 11: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Methods

• Trauma ICU pts recruited 24hrs post admission• Baseline blood sample• Injection of 1mL 25 µCi of 131I-albumin• 12 minute equilibration period

– Then 5 serial blood draws, 6 minutes apart• Samples processed on BVA-100 Blood Volume

Analyzer (Daxor Corporation, NY, NY)

Page 12: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Methods

Measured volumes compared to ideal -- percent deviation from ideal calculated

Page 13: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Methods

• Pts stratified into 3 groups based on deviation from ideal total blood volume– Hypovolemic: > 8% deficit relative to ideal– Normovolemic: < 8% variation relative to ideal – Hypervolemic: > 8% excess relative to ideal

Page 14: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

CharacteristicsPatients (n = 27)

Male / Female 13 / 14

Age 49.6 ± 3.8

Body Mass Index 29.3 ± 6.2

APACHE II 17.9 ± 1.5

Injury Severity Score 29.8 ± 2.5

All values are mean ± standard deviation

Page 15: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Results

Hyper-volemic50.8%

Normo-volemic30.8%

Hypo-volemi

c18.4%

Volume status (n = 65)

Page 16: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Volume Status and Fluids

Hypovolemic(n = 12)

Normovolemic(n =19)

Hypervolemic(n = 33)

Fluid In (mL) 17,881(10065, 41396)

30,306(14752, 52026)

22,016(18100, 33397)

Net Fluid (mL) 13,579(4702, 18708)

2,799(1969, 15861)

11,807(6924, 17373)

All values are medians (interquartile range)All p = NS, Mann-Whitney U test

No significant difference in volume of fluids given or net fluid balance between each volume status

Page 17: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Results

• No linear correlation between net fluid balance and changes in TBV, RBCV, and PV between each analysis

• Moderate linear correlation between pHct and RBCV (R2 = 0.3)

Page 18: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Results

• No differences in ISS when compared across the volume status groups

• No correlation between ISS and rate of albumin transudation

Page 19: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

pHct versus nHctpHct nHct Difference pHct < 30 nHct < 30 Overdiagnosi

s of anemiaHypovolemic

(n=12) 26.1 20.9* 5.2 ± 3.3 91.7% (11) 91.7% (11) --

Normovolemic(n=20) 27.1 27.1 0.0 ± 1.2 80.0% (16) 80.0% (16) --

Hypervolemic(n=33) 26.5 32.9* -6.4 ± 4.4 81.8% (27) †27.3% (9) 54.5% (18)

All(n=65) 26.6 28.9 -2.3 ± 5.7 83.1% (54) 55.4% (36) 27.7% (18)

Paired t-test* p < 0.05

Chi-squared† p < 0.05

Page 20: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Conclusions

• Assessing volume status is challenging• No differences in amount of fluids

administered to volume status groups• pHct compared to nHct

– Overestimates anemia in hypervolemic pts– Underestimates anemia in hypovolemic pts

Page 21: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Limitations

• Preliminary study -- small number of patients • BVA not a dynamic test – snapshot in time• Assume RBCV constant during testing

– Not reasonable if bleeding > 100mL/hr• Availability of tracer and personnel

Page 22: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Future Directions

• Further characterize effects of fluid and blood product administration on volume status

• Blood volume analysis upon ICU admission– Establish baseline– Initiate therapies based on blood volumes– Avoid unnecessary CT scans and transfusion when

BVA shows low pHct due to hemodilution

Page 23: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD
Page 24: PY Van, MD ∙ SD Cho, MD ∙ SJ Underwood, MS GJ Hamilton, BS ∙ LB Ham, MD ∙ MA Schreiber, MD

Blood Volume Analysis


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