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Blood Volume Blood Volume AnalysisAnalysis
in Clinical Practicein Clinical PracticeChris HirtChris Hirt
Daxor CorporationDaxor CorporationAccount ManagerAccount [email protected]@daxor.com
410-499-7840410-499-7840
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Ways to assess volume Ways to assess volume statusstatus
Direct Measurement:•Analysis with Daxor BVA-100
•Vital signs: BP, HR •Input/Output, weights•Jugular venous distension•Lung sounds•Central Venous pressure•Edema present/absent•Hematocrit/Hemoglobin•Pulmonary Artery Catheterization
Clinical indicators (indirect):
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How does BVA work?How does BVA work? Indicator Dilution TechniqueIndicator Dilution Technique
131131I labeled albumin (15 microcuries)I labeled albumin (15 microcuries) 1.0 ml dosimetric syringe1.0 ml dosimetric syringe Very small radiation doseVery small radiation dose1.
Inject knownamount /volume
of tracer
3.Measure tracerconcentration,
calculate volume
2.Wait for
equilibrium
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BLOOD VOLUME ANALYSIS - FINAL REPORTBLOOD VOLUME ANALYSIS - FINAL REPORTPatient Name:Patient Name:Identification Number: 096784758Identification Number: 096784758Height: 61.5 Inches Height: 61.5 Inches Weight: 126.5 Pounds (Dev. from Ideal: 9.3%)Weight: 126.5 Pounds (Dev. from Ideal: 9.3%)Comments: V32406-86 Comments: V32406-86 Gender: FemaleGender: FemaleAnalyzed on: 07/14/2003 at 17:42:54 by: Dr.L & JRAnalyzed on: 07/14/2003 at 17:42:54 by: Dr.L & JR
Sample Time Sample Time Hct-A Hct-A Hct-B Hct-B Avg Avg Count-A Count-A Count-B Count-B AvgCnt UnadjVolAvgCnt UnadjVol--------------------------------------------------------------------------------------------------------------------------------------------------------------Control Control 37.5 37.5 37.7 37.7 37.6 37.6 78 78 72 72 7575Standard-1Standard-1 1208112081 1260312603 1234212342Pat-Samp-1 12.0 Pat-Samp-1 12.0 36.6 36.6 36.6 36.6 36.6 36.6 5953 5953 6220 6220 6086 30436086 3043Pat-Samp-2 18.0 Pat-Samp-2 18.0 36.5 36.5 36.7 36.7 36.6 36.6 6137 6137 5920 5920 6029 30736029 3073Pat-Samp-3 24.0 Pat-Samp-3 24.0 36.6 36.6 36.1 36.1 36.3 36.3 6018 6018 5880 5880 5949 31045949 3104Pat-Samp-4 30.0 Pat-Samp-4 30.0 36.5 36.5 36.4 36.4 36.5 36.5 5863 5863 5729 5729 5796 31915796 3191Pat-Samp-5 36.0 Pat-Samp-5 36.0 36.2 36.2 36.5 36.5 36.4 36.4 5701 5701 5563 5563 5632 32815632 3281--------------------------------------------------------------------------------------------------------------------------------------------------------------Room Background: 80 counts. Sample Acquisition Time was 3.00 min.Room Background: 80 counts. Sample Acquisition Time was 3.00 min.Anti-Coagulation Factor: 1.00 Isotope: I-131 Dose: 9.5 microCiAnti-Coagulation Factor: 1.00 Isotope: I-131 Dose: 9.5 microCi++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++Blood Vol.: 2910 ml Blood Vol.: 2910 ml Ideal Vol.: 3721 ml Ideal Vol.: 3721 ml Deficit: 811 ml Deficit: 811 ml Devtn.: -21.8 Devtn.: -21.8
%%Red Cell Vol.: 956 ml Red Cell Vol.: 956 ml Ideal Vol.: 1341 mlIdeal Vol.: 1341 ml Deficit: 385 ml Deficit: 385 ml
Devtn.: -28.7 %Devtn.: -28.7 %Plasma Vol.: 1953 ml Plasma Vol.: 1953 ml Ideal Vol.: 2380 ml Ideal Vol.: 2380 ml Deficit: 426 ml Deficit: 426 ml Devtn.: -17.9 Devtn.: -17.9
%%
Patient Blood Volume is: HYPOVOLEMIC Patient Blood Volume is: HYPOVOLEMIC Normalized HCT is: 28.5%Normalized HCT is: 28.5%
Slope is: 0.00314Slope is: 0.00314Standard Deviation is: 33.7 ml ( 1.159% )Standard Deviation is: 33.7 ml ( 1.159% )-------------------------------------------------------------------------------------------------------------------------------------------------------------- Normal Mild Moderate Severe Extreme Normal Mild Moderate Severe Extreme BV, PV Deviation (+/- %): BV, PV Deviation (+/- %): 0 to 8 >8 to 16 >16 to 24 >24 to 32 >32 0 to 8 >8 to 16 >16 to 24 >24 to 32 >32RCV Deviation (%)RCV Deviation (%) 0 to 10 >10 to 20 >20 to 30 >30 to 40 >40 0 to 10 >10 to 20 >20 to 30 >30 to 40 >40
Report Example - Report Example - HypovolemiaHypovolemia
BVA Normal
and Abnormal Ranges
Patient Results
Bench Work
performed by Nuclear Medicine
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BLOOD VOLUME ANALYSIS - FINAL REPORTBLOOD VOLUME ANALYSIS - FINAL REPORTPatient Name:Patient Name:Identification Number: 096784758Identification Number: 096784758Height: 61.5 Inches Height: 61.5 Inches Weight: 126.5 Pounds (Dev. from Ideal: 9.3%)Weight: 126.5 Pounds (Dev. from Ideal: 9.3%)Comments: V32406-86 Comments: V32406-86 Gender: FemaleGender: FemaleAnalyzed on: 07/14/2003 at 17:42:54 by: Dr.L & JRAnalyzed on: 07/14/2003 at 17:42:54 by: Dr.L & JR
Sample Time Sample Time Hct-A Hct-A Hct-B Hct-B Avg Avg Count-A Count-A Count-B Count-B AvgCnt UnadjVolAvgCnt UnadjVol--------------------------------------------------------------------------------------------------------------------------------------------------------------Control Control 37.5 37.5 37.7 37.7 37.6 37.6 78 78 72 72 7575Standard-1Standard-1 1208112081 1260312603 1234212342Pat-Samp-1 12.0 Pat-Samp-1 12.0 36.6 36.6 36.6 36.6 36.6 36.6 5953 5953 6220 6220 6086 30436086 3043Pat-Samp-2 18.0 Pat-Samp-2 18.0 36.5 36.5 36.7 36.7 36.6 36.6 6137 6137 5920 5920 6029 30736029 3073Pat-Samp-3 24.0 Pat-Samp-3 24.0 36.6 36.6 36.1 36.1 36.3 36.3 6018 6018 5880 5880 5949 31045949 3104Pat-Samp-4 30.0 Pat-Samp-4 30.0 36.5 36.5 36.4 36.4 36.5 36.5 5863 5863 5729 5729 5796 31915796 3191Pat-Samp-5 36.0 Pat-Samp-5 36.0 36.2 36.2 36.5 36.5 36.4 36.4 5701 5701 5563 5563 5632 32815632 3281--------------------------------------------------------------------------------------------------------------------------------------------------------------Room Background: 80 counts. Sample Acquisition Time was 3.00 min.Room Background: 80 counts. Sample Acquisition Time was 3.00 min.Anti-Coagulation Factor: 1.00 Isotope: I-131 Dose: 9.5 microCiAnti-Coagulation Factor: 1.00 Isotope: I-131 Dose: 9.5 microCi++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++Blood Vol.: 2910 ml Ideal Vol.: 3721 ml Deficit: 811 ml Devtn.: -21.8 %Red Cell Vol.: 956 ml Ideal Vol.: 1341 ml Deficit: 385 ml Devtn.: -28.7 %Plasma Vol.: 1953 ml Ideal Vol.: 2380 ml Deficit: 426 ml Devtn.: -17.9 %
Patient Blood Volume is: HYPOVOLEMIC Normalized HCT is: 28.5%
Slope is: 0.00314Slope is: 0.00314Standard Deviation is: 33.7 ml ( 1.159% )Standard Deviation is: 33.7 ml ( 1.159% )-------------------------------------------------------------------------------------------------------------------------------------------------------------- Normal Mild Moderate Severe Extreme BV, PV Deviation (+/- %): 0 to 8 >8 to 16 >16 to 24 >24 to 32 >32RCV Deviation (%) 0 to 10 >10 to 20 >20 to 30 >30 to 40 >40
Report Example - Report Example - HypovolemiaHypovolemia
BVA Normal
and Abnormal Ranges
Patient Results
Bench Work
performed by Nuclear Medicine
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Normalized Peripheral Normalized Peripheral Hematocrit Hematocrit
NPHct = Normalized Peripheral HematocritNPHct = Normalized Peripheral Hematocrit Is the change in the hematocrit that would occur Is the change in the hematocrit that would occur
by adjusting the plasma volume so that the by adjusting the plasma volume so that the patient’s whole blood volume is at the ideal blood patient’s whole blood volume is at the ideal blood volume.volume.
NPHct = NPHct = mBV mBV x MPHCT x MPHCT iBViBV
EXAMPLE #1EXAMPLE #1 Patient with ideal blood volume of 5,000 ml, Patient with ideal blood volume of 5,000 ml,
measured blood volume 4,000ml, hematocrit of measured blood volume 4,000ml, hematocrit of 40%40%4,000 4,000 x 40 = 32% (normalized hematocrit) x 40 = 32% (normalized hematocrit)5,0005,000
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Normovolemic Normovolemic Hypovolemic
Normal red cell Anemia Anemia
5000cc 5000cc
Common Surrogate MarkersCommon Surrogate MarkersHematocrit & HemoglobinHematocrit & Hemoglobin
3750cc
Hypervolemic Normal red cell
6500cc
30%
Surrogate Markers Do Not Provide A Blood Volume Measurement
30% 30% 45%Hematocrit
Red Blood CellVolume
Plasma Volume
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The Process – Why Five The Process – Why Five Data Points?Data Points?
Mixing TimeMixing Time TransudationTransudation AccuracyAccuracy
Time (min)>>
Tracer Concentration
Measured BV (ln)x
xx
xx
12 36
BV
Mix
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4800
5000
5200
5400
5600
5800
6000
6200
6400
0 12 18 24 30 36
Septic Sock Normal
BVA in Septic Shock / Trauma
“Slope” reflects albumin transudation from vascular compartment In normal subjects, the rate of movement of albumin across the
capillary bed into the lymphatic system is approximately 0.0025% per minute.
Increased slope suggests increased capillary permeability, a possible measure of systemic inflammatory response, particularly in septic shock.
Time Point Of Sampling - Minutes
Ca
lcu
late
d I
ntr
av
as
cu
lar
Vo
lum
e -
ml
Important Point!
An important point to remember is that a normal rate of transudation does not necessarily rule out capillary damage. The reason for this is that in situations where the intravascular albumin level drops and the extra vascular level increases, the decrease in albumin gradient may result in a stabilization in the rate of transudation. This condition can be suspected in situations where patients have low serum albumin levels. The ultimate proof of this hypothesis is to actually measure total body albumin.
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Blood Volume AnalyzerBlood Volume Analyzer
1. Congestive Heart Failure1. Congestive Heart Failure
2. Syncope 2. Syncope
3. Hypertension3. Hypertension
4. Chronic Hypotension 4. Chronic Hypotension
5. Orthostatic Hypotension5. Orthostatic Hypotension
6. POTS Syndrome6. POTS Syndrome
7. Polycythemia7. Polycythemia
9. Renal Dialysis9. Renal Dialysis
10. Pre/Post Surgical Volume 10. Pre/Post Surgical Volume StatusStatus
11. Blood Transfusion 11. Blood Transfusion Assessment Assessment
12. Pre-Operative Hemodilution12. Pre-Operative Hemodilution
13. Pre-Operative screening for 13. Pre-Operative screening for hypovolemiahypovolemia
14. Shock14. Shock
Medical Conditions
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Clinical Application—Clinical Application—Critical CareCritical Care
ICU, CCU, SICUICU, CCU, SICU Determine red blood cell and plasma volume Determine red blood cell and plasma volume
status in critically ill patients to guide treatment.status in critically ill patients to guide treatment. Identify hypovolemia in the presence of septic Identify hypovolemia in the presence of septic
shock or peripheral edema.shock or peripheral edema. Differentiate Differentiate dilutionaldilutional from from hypovolemichypovolemic from from
normovolemicnormovolemic anemia. anemia. Differentiate IADHS from hyponatremia/renal salt Differentiate IADHS from hyponatremia/renal salt
wasting syndrome.wasting syndrome. Define a true intravascular volume status for Define a true intravascular volume status for
patients receiving ultrafiltration or CRRT therapy. patients receiving ultrafiltration or CRRT therapy.
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Correlation Between Blood Correlation Between Blood Volume and Pulmonary Artery Volume and Pulmonary Artery Catheter MeasurementsCatheter MeasurementsElisabeth Biuk-Aghai MD, Hideko Yamauchi MD, Mihae Yu MD, Hao Chih Ho MD, Elisabeth Biuk-Aghai MD, Hideko Yamauchi MD, Mihae Yu MD, Hao Chih Ho MD, Alyssa Chapital MD, Danny Takanishi MDAlyssa Chapital MD, Danny Takanishi MDDepartment of Surgery, Division of Surgical Critical Care, Queen’s Medical Center, Department of Surgery, Division of Surgical Critical Care, Queen’s Medical Center, University of Hawaii, Honolulu, HIUniversity of Hawaii, Honolulu, HI Purpose: to investigate the relationship between parameters obtained Purpose: to investigate the relationship between parameters obtained
from a PAC and simultaneous measurments of blood volume. from a PAC and simultaneous measurments of blood volume. Twenty ICU patients contributed 29 simultaneous blood volume and Twenty ICU patients contributed 29 simultaneous blood volume and
PAC values. PAC values. Euvolemia was present in 11 of 29 instances, hypervolemia in 17 of 29, Euvolemia was present in 11 of 29 instances, hypervolemia in 17 of 29,
with 1 value demonstrating hypovolemia. with 1 value demonstrating hypovolemia. Although there was a statistically significant relationship between PAOP Although there was a statistically significant relationship between PAOP
and BV, BV information resulted in different treatment in 6 out of 29 and BV, BV information resulted in different treatment in 6 out of 29 (21% of the time) with 4 of the 6 times showing clinical improvement (21% of the time) with 4 of the 6 times showing clinical improvement when BV information was used.when BV information was used.
Regardless of the different ranges of the PAOP it was difficult to predict Regardless of the different ranges of the PAOP it was difficult to predict euvolemia vs. hypervolemia. All patients had skin edema from shock euvolemia vs. hypervolemia. All patients had skin edema from shock and resuscitation and assessment of intravascular blood volume was and resuscitation and assessment of intravascular blood volume was difficult. difficult.
ConclusionConclusion: There may be a role for BV measurment in patients after : There may be a role for BV measurment in patients after the acute resuscitation when there is a clinical dilemma regarding the acute resuscitation when there is a clinical dilemma regarding blood volume treatment. Due to the limitations of a retrospective study, blood volume treatment. Due to the limitations of a retrospective study, we cannot infer outcomes until a prospective randomized study is done. we cannot infer outcomes until a prospective randomized study is done.
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Relationships between Blood VolumeRelationships between Blood Volumeand Pulmonary Artery Occlusion and Pulmonary Artery Occlusion
PressurePressure
Although there was a statistically significant correlation between PAOP and BV, PAOP level (≤12 mm Although there was a statistically significant correlation between PAOP and BV, PAOP level (≤12 mm Hg, 13-18 mm Hg, or >18 mm Hg) could not be used to predict euvolemia vs. hypervolemia. BV Hg, 13-18 mm Hg, or >18 mm Hg) could not be used to predict euvolemia vs. hypervolemia. BV results led to different treatment in 6 out of 29 (21%) instances, with 4/6 times showing subsequent results led to different treatment in 6 out of 29 (21%) instances, with 4/6 times showing subsequent clinical improvement.clinical improvement.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Euvolemia(n = 4)
Hypervolemia(n = 2)
Hypervolemia(n = 6)
Hypervolemia(n = 9)
Euvolemia(n = 3)
Euvolemia(n = 4)
Hypo (n=1)
PAOP (mmHg)<=12
(n = 6)>=18
(n = 9)13-17
(n = 14)
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How to order Blood Volume How to order Blood Volume Analysis?Analysis?
Go to Power ChartGo to Power Chart Enter “Whole Blood Volume” and Enter “Whole Blood Volume” and
you will be presented with an you will be presented with an existing orderable. existing orderable.
*In the comment section please put *In the comment section please put BVA methodBVA method.*.*
