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Volume Assessment

Volume Assessment. 2010. Old Paradigm. Na + = Volume H 2 O = Tonicity. ICF. ECF. Blood. TBW. Left sided failure DOE Orthopnea 90% sensitivity corr c pcwp PND. Right-sided Failure Abdominal pain Early satiety Nausea/vomiting Non-specific Fatigue Feeling cold Altered mentation.

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Volume Assessment

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  1. Volume Assessment 2010

  2. Old Paradigm Na+ = Volume H2O = Tonicity ICF ECF Blood TBW

  3. Left sided failure DOE Orthopnea 90% sensitivity corr c pcwp PND Right-sided Failure Abdominal pain Early satiety Nausea/vomiting Non-specific Fatigue Feeling cold Altered mentation Signs & Symptoms: Volume Overload

  4. Physical Exam For Volume Excess States • Lung ascultation – rales (20% with inc pcwp) • CVS – S3 • JVP (70% sens/79% spec) • Rondot sign, abd-jugular reflux (inc sens/spec to 80%) / Valsalva maneuver (82% predictive) • Edema (50%, less in young adults/children)

  5. Don’t Forget • Daily Weight • I/O???

  6. JVD

  7. Laboratory Assessment • BNP (29pmol/l or 100 pg/ml 96% neg predictive value) • NT-proBNP (14.75 pmol/l or 125 pg/ml for <75 yo and 53.1pmol/l or 450 pg/ml for >75 100% neg predictive value) • Nohria et al AmJCard 2005;96:32G

  8. BNP and PCWP J Card Fail 2001;7:21

  9. BNP/proNT-BNP and CKD Vickery et al. Am J Kidney Dis 46:610

  10. Bedside Tests • CXR • Cardiogenic vs. • Non-cardiogenic

  11. CVP • CVP corr coef 0.16 with blood vol • CVP corr 0.18 with stroke index Osman et al Crit Care Med 2007; 35:64

  12. Swann vs. Clinician ESCAPE study Am Heart J 2001;141:528

  13. PCWP and Volume Expansion Osman et al Crit Care Med 2007; 35:64

  14. Bioimpedance BIG substudy of ESCAPE Am Heart J 2009;158: 217-223

  15. Where does sodium go? Heer M, Baisch F, Kropp J, Gerzer R, Drummer C: High dietary sodium chloride consumption may not induce body fluid retention in humans. Am J Physiol Renal Physiol 278:F585

  16. Skin? Dry Weight Schafflhuber M, Volpi N, Dahlmann A, Hilgers KF, Maccari F,Dietsch P, Wagner H, Luft FC, Eckardt KU, Titze J: Mobilization of osmotically inactive Na+ by growth and by dietary salt restriction in rats. Am J Physiol Renal Physiol 292:F1490

  17. How can sodium be made osmotically inactive? Macrophages regulate salt-dependent volume and blood pressure by a vascular endothelial growth factor-C–dependent buffering mechanism Agnes Machnik1, Wolfgang Neuhofer2, Jonathan Jantsch1,3, Anke Dahlmann1, Tuomas Tammela4,Katharina Machura5, Joon-Keun Park6, Franz-Xaver Beck2, Dominik N Mu¨ller7, Wolfgang Derer8,Jennifer Goss1, Agata Ziomber1, Peter Dietsch9, Hubertus Wagner10, Nico van Rooijen11, Armin Kurtz5,Karl F Hilgers1, Kari Alitalo4, Kai-Uwe Eckardt1, Friedrich C Luft7,8, Dontscho Kerjaschki12 & Jens Titze1

  18. 1. High salt diet leads to hypertonic sodium accumulation in skin via hyperplasia of lymphcapillaries.

  19. 2. Activation of tonicity-responsive enhancer binding protein (TonEBP) in mononuclear phagocyte system (MPS) cells infiltrating the interstitium of the skin LS vs. HS

  20. 3. TonEBP binds the promoter of the geneencoding vascular endothelial growth factor-C

  21. 4. MPS depletion or VEGF-C trapping by soluble VEGF receptor-3 blocks VEGF-C signaling, augments interstitial hypertonic volumeretention, decreases endothelial nitric oxide synthase expression and elevates blood pressure in response to HSD. Extracellular volume Intracellular volume Clondronate liposomes deplete MPS, PBS liposomes were controls

  22. VEGF-C and Kidneys H van Goor,H Leuvenink, Kidney International (2009) 75, 767

  23. New Paradigm Na+ = Volume H2O = Tonicity ICF ECF sequestered Blood TBW

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