Lai Chih-Jun, Shih Chung-Chih, Huang Hsing-Hao, Chien Ming-Hung, Wu Ming-Shiou, Cheng Ya-Jung
Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan.
Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan.
Front Physiol. 2022 Apr 28;13:775631. doi: 10.3389/fphys.2022.775631. eCollection 2022.
Unstable hemodynamics are not uncommon during hemodialysis (HD), which involves a rapid volume depletion, taking the patient from hypervolemia toward euvolemia. Since uremic patients commonly have cardiovascular comorbidities, hemodynamic changes during HD may reflect interactions among the volemic, cardiac, and autonomic responses to gradual volume depletion during ultrafiltration. Accurate identification of inappropriate responses helps with precisely managing intradialytic hypotension. Recently, the non-invasive ClearSight was reported to be able to detect causes of intraoperative hypotension. In this prospective observational study, we aimed to determine whether ClearSight could be used to detect patterns in stroke volemic, cardiac, and vasoreactive responses during HD. ClearSight was used to monitor chronic stable patients receiving maintenance HD. Data of mean arterial blood pressure (MAP), heart rate (HR), stroke volume index (SVI), cardiac index (CI), and calculated systemic vascular resistance index (SVRI) were obtained and analyzed to examine patterns in volemic, cardiac, and vasoreactive changes from T0 (before HD) until T8 in 30-min intervals (total 4 h). A total of 56 patients with a mean age of 60.5 years were recruited, of which 40 of them were men. The average ultrafiltration volume at T8 was 2.1 ± 0.8 L. The changes in MAP and HR from T0 to T8 were non-significant. SVI at T7 was significantly lower than that at T1, T2, and T3. CI at T4 to T8 was significantly lower than that at T0. SVRI was significantly higher at T3 to T8 than at T0. Pearson's correlation coefficients between SVI and CI and between SVRI and MAP were positive at all time points. The correlation coefficients between SVRI and SVI and between CI and SVRI were significant and negative for all time points. ClearSight was able to detect patterns in hypervolemia during HD and was well tolerated for 4 h. CI decreased significantly after T4, with slightly decreased SVI. Ultrafiltration volume was not correlated with changes in SVI or CI. The vascular tone increased significantly, and this counteracted the reduced cardiac output after T4. With simultaneous monitoring on SVI, CI, and SVRI during HD, therefore, hypotension could be detected and managed by reducing the filtration rate or administering inotrope or vasopressors. clinicaltrials.gov, ID: NCT03901794.
血液透析（HD）期间不稳定的血流动力学并不罕见，这涉及快速的容量消耗，使患者从高血容量状态转变为血容量正常状态。由于尿毒症患者通常伴有心血管合并症，HD期间的血流动力学变化可能反映了超滤过程中血容量、心脏和自主神经对逐渐的容量消耗的反应之间的相互作用。准确识别不适当的反应有助于精确管理透析期间的低血压。最近，有报道称无创ClearSight能够检测术中低血压的原因。在这项前瞻性观察研究中，我们旨在确定ClearSight是否可用于检测HD期间每搏量、心脏和血管反应性的变化模式。使用ClearSight监测接受维持性HD的慢性稳定患者。获取并分析平均动脉血压（MAP）、心率（HR）、每搏量指数（SVI）、心脏指数（CI）和计算得出的全身血管阻力指数（SVRI）的数据，以检查从T0（HD前）到T8以30分钟为间隔（共4小时）的血容量、心脏和血管反应性变化模式。共招募了56名平均年龄为60.5岁的患者，其中40名是男性。T8时的平均超滤量为2.1±0.8L。从T0到T8，MAP和HR的变化不显著。T7时的SVI显著低于T1、T2和T3时。T4到T8时的CI显著低于T0时。T3到T8时的SVRI显著高于T0时。在所有时间点，SVI与CI之间以及SVRI与MAP之间的Pearson相关系数均为正。在所有时间点，SVRI与SVI之间以及CI与SVRI之间的相关系数均显著且为负。ClearSight能够检测HD期间的高血容量模式，并且在4小时内耐受性良好。T4后CI显著下降，SVI略有下降。超滤量与SVI或CI的变化无关。血管张力显著增加，这抵消了T4后心输出量的减少。因此，在HD期间同时监测SVI、CI和SVRI，可以通过降低滤过率或给予正性肌力药物或血管升压药来检测和管理低血压。clinicaltrials.gov，标识符：NCT03901794。
