Hypervolemia is associated with increased mortality among hemodialysis patients

Making measures count

An abundance of available laboratory information has led in part to the establishment of quantitative performance goals that use serum albumin, hemoglobin, Kt/V, and bone mineral indices to track quality of medical care and even physician reimbursement. As we look to the future, the next generation of measures should should more specifically reflect efforts to improve more fundamental outcomes, such as mortality, hospitalization, and quality of life. In this essay we address the important question of how clinicians can translate rich sources of quantitative data into a service that makes a difference in our patients' lives; a way to distinguish exemplary from ordinary care; a means to support continuous improvement in our care patterns individually and as part of larger, integrated health care systems all while avoiding prematurely advocating flawed quality measures. We also offer a pathway for how future quality measures can be developed. Our ultimate goal is to individualize quantitative assessments and by doing so encourage more meaningful, patient-oriented care that will lead to improved outcomes, greater physician job satisfaction, and wiser allocation of scarce resources.

Inferior vena cava diameter and left atrial diameter measure volume but not dry weight

BACKGROUND AND OBJECTIVES

Hypervolemia is an important and modifiable cause of hypertension. Hypertension improves with probing dry weight, but its effect on echocardiographic measures of volume is unknown.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Shortly after dialysis, echocardiograms were obtained at baseline and longitudinally every 4 weeks on two occasions. Among 100 patients in the additional ultrafiltration group, 198 echocardiograms were performed; among 50 patients in the control group, 104 echocardiograms were performed.

RESULTS

Baseline inferior vena cava (IVC)(insp) diameter was approximately 5.1 mm/m(2); with ultrafiltration, change in IVC(insp) diameter was -0.95 mm/m(2) more compared with the control group at 4 weeks and -1.18 mm/m(2) more compared with the control group at 8 weeks. From baseline IVC(exp) diameter of approximately 8.2 mm/m(2), ultrafiltration-induced change at 4 weeks was -1.06 mm/m(2) more and at 8 weeks was -1.07 mm/m(2) more (P=0.044). From a baseline left atrial diameter of 2.1 cm/m(2), ultrafiltration-induced change at 4 weeks was -0.14 cm/m(2) more and at 8 weeks was -0.15 cm/m(2) more. At baseline, there was no relationship between interdialytic ambulatory BP and echocardiographic parameters of volume. The reduction in interdialytic ambulatory BP was also independent of change in the echocardiographic volume parameters.

CONCLUSIONS

The inferior vena cava and left atrial diameters are echocardiographic parameters that are responsive to probing dry weight; thus, they reflect excess volume. However, echocardiographic volume parameters are poor determinants of interdialytic BP, and their change does not predict the BP response to probing dry weight.

Treatment of posthemorrhagic hydrocephalus in premature infants with subcutaneous reservoir drainage

AIMS

To investigate the effectiveness of subcutaneous reservoir drainage as a treatment for the different types of posthemorrhagic hydrocephalus in premature infants.

METHODS

11 premature infants with posthemorrhagic hydrocephalus underwent subcutaneous reservoir embedment surgery, and cerebrospinal fluid (CSF) was drained via the reservoir intermittently for 8 weeks. During the period of drainage, ultrasound and computerized tomography were used to measure ventricle size. CSF examinations were performed routinely to assess the presence of intraventricular hemorrhage (IVH) and/or infection.

RESULTS

(1) Five infants were diagnosed as having obstructive hydrocephalus; 2 had nearly normal ventricle sizes with treatment and drainage was stopped after 8 weeks, 2 had nearly normal ventricle sizes after 4 more weeks of drainage, and 1 underwent ventriculoperitoneal shunt (V-P shunt) surgery due to failure of ventricle size reduction. (2) Six infants were diagnosed as having communicating hydrocephalus; 4 had further enlarged ventricle size after 8 weeks and underwent V-P shunt surgery, 1 had treatment aborted at week 8 of drainage, and only 1 had moderate reduction of ventricle size after 8 weeks. (3) None of the 11 infants had progressive IVH and/or intracranial infection during drainage.

CONCLUSIONS

Subcutaneous reservoir drainage is a suitable and safe treatment for posthemorrhagic hydrocephalus in premature infants. It is more effective for obstructive hydrocephalus than for communicating hydrocephalus.