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Stenson EK, Banks RK, Reeder RW, Maddux AB, Zimmerman J, Meert KL, Mourani PM. Fluid Balance and Its Association With Mortality and Health-Related Quality of Life: A Nonprespecified Secondary Analysis of the Life After Pediatric Sepsis Evaluation. Pediatr Crit Care Med 2023; 24:829-839. [PMID: 37260317 PMCID: PMC10689573 DOI: 10.1097/pcc.0000000000003294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To evaluate the association between fluid balance (FB) and health-related quality of life (HRQL) among children at 1 month following community-acquired septic shock. DESIGN Nonprespecified secondary analysis of the Life After Pediatric Sepsis Evaluation. FB was defined as 100 × [(cumulative PICU fluid input - cumulative PICU fluid output)/PICU admission weight]. Three subgroups were identified: low FB (< 5%), medium FB (5%-15%), and high FB (> 15%) based on cumulative FB on days 0-3 of ICU stay. HRQL was measured at ICU admission and 1 month after using Pediatric Quality of Life Inventory 4.0 Generic Core or Infant Scales or the Stein-Jessop Functional Status Scale. The primary outcome was a composite of mortality or greater than 25% decline in HRQL 1 month after admission compared with baseline. SETTING Twelve academic PICUs in the United States. PATIENTS Critically ill children between 1 month and 18 years, with community-acquired septic shock who survived to at least day 4. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two hundred ninety-three patients were included of whom 66 (23%) had low FB, 127 (43%) had medium FB, and 100 (34%) had high FB. There was no difference in Pediatric Risk of Mortality Score 3 (median 11 [6, 17]), age (median 5 [1, 12]), or gender (47% female) between FB groups. After adjusting for potential confounders and comparing with medium FB, higher odds of mortality or greater than 25% HRQL decline were seen in both the low FB (odds ratio [OR] 2.79 [1.20, 6.57]) and the high FB (OR 2.16 [1.06, 4.47]), p = 0.027. Compared with medium FB, low FB (OR 4.3 [1.62, 11.84]) and high FB (OR 3.29 [1.42, 8.00]) had higher odds of greater than 25% HRQL decline. CONCLUSIONS Over half of the children who survived septic shock had low or high FB, which was associated with a significant decline in HRQL scores. Prospective studies are needed to determine if optimization of FB can improve HRQL outcomes.
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Affiliation(s)
- Erin K. Stenson
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Colorado, Aurora, CO
| | - Russell K Banks
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron W. Reeder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Aline B. Maddux
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Colorado, Aurora, CO
| | - Jerry Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Kathleen L. Meert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Peter M. Mourani
- Section of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR
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Colucci LA, Corapi KM, Li M, Parada XV, Allegretti AS, Lin HY, Ausiello DA, Rosen MS, Cima MJ. Fluid assessment in dialysis patients by point-of-care magnetic relaxometry. Sci Transl Med 2020; 11:11/502/eaau1749. [PMID: 31341060 DOI: 10.1126/scitranslmed.aau1749] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/12/2019] [Accepted: 05/23/2019] [Indexed: 01/12/2023]
Abstract
Magnetic resonance imaging (MRI) is a powerful diagnostic tool, but its use is restricted to the scanner suite. Here, we demonstrate that a bedside nuclear magnetic resonance (NMR) sensor can assess fluid status changes in individuals at a fraction of the time and cost compared to MRI. Our study recruited patients with end-stage renal disease (ESRD) who were regularly receiving hemodialysis treatments with intradialytic fluid removal as a model of volume overload and healthy controls as a model of euvolemia. Quantitative T 2 measurements of the lower leg of patients with ESRD immediately before and after dialysis were compared to those of euvolemic healthy controls using both a 0.28-T bedside single-voxel NMR sensor and a 1.5-T clinical MRI scanner. In the MRI data, we found that the first sign of fluid overload was an expanded muscle extracellular fluid (ECF) space, a finding undetectable at this stage using physical exam. A decrease in muscle ECF upon fluid removal was similarly detectable with both the bedside sensor and MRI. Bioimpedance measurements performed comparably to the bedside NMR sensor but were generally worse than MRI. These findings suggest that bedside NMR may be a useful method to identify fluid overload early in patients with ESRD and potentially other hypervolemic patient populations.
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Affiliation(s)
- Lina A Colucci
- Harvard-MIT Division of Health Sciences and Technology (HST), Cambridge, MA 02139, USA.,Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Kristin M Corapi
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Matthew Li
- Harvard-MIT Division of Health Sciences and Technology (HST), Cambridge, MA 02139, USA.,Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Xavier Vela Parada
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Herbert Y Lin
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Dennis A Ausiello
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Matthew S Rosen
- A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA 02129, USA.,Department of Physics, Harvard University, Cambridge, MA 02138, USA
| | - Michael J Cima
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA. .,Department of Materials Science and Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
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Bashyam A, Frangieh CJ, Li M, Cima MJ. Dehydration assessment via a portable, single sided magnetic resonance sensor. Magn Reson Med 2019; 83:1390-1404. [PMID: 31631380 DOI: 10.1002/mrm.28004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/21/2019] [Accepted: 08/28/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Undiagnosed dehydration compromises health outcomes across many populations. Existing dehydration diagnostics require invasive bodily fluid sampling or are easily confounded by fluid and electrolyte intake, environment, and physical activity limiting widespread adoption. We present a portable MR sensor designed to measure intramuscular fluid shifts to identify volume depletion. METHODS Fluid loss is induced via a mouse model of thermal dehydration (37°C; 15-20% relative humidity). We demonstrate quantification of fluid loss induced by hyperosmotic dehydration with multicomponent T2 relaxometry using both a benchtop NMR system and MRI localized to skeletal muscle tissue. We then describe a miniaturized (~1000 cm3 ) portable (~4 kg) MR sensor (0.28 T) designed to identify dehydration-induced fluid loss. T2 relaxometry measurements were performed using a Carr-Purcell-Meiboom-Gill pulse sequence in ~4 min. RESULTS T2 values from the portable MR sensor exhibited strong (R2 = 0.996) agreement with benchtop NMR spectrometer. Thermal dehydration induced weight loss of 4 to 11% over 5 to 10 h. Fluid loss induced by thermal dehydration was accurately identified via whole-animal NMR and skeletal muscle. The portable MR sensor accurately identified dehydration via multicomponent T2 relaxometry. CONCLUSION Performing multicomponent T2 relaxometry localized to the skeletal muscle with a miniaturized MR sensor provides a noninvasive, physiologically relevant measure of dehydration induced fluid loss in a mouse model. This approach offers sensor portability, reduced system complexity, fully automated operation, and low cost compared with MRI. This approach may serve as a versatile and portable point of care technique for dehydration monitoring.
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Affiliation(s)
- Ashvin Bashyam
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Department of Electrical Engineering & Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Chris J Frangieh
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Department of Electrical Engineering & Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Matthew Li
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Harvard-MIT Program in Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Michael J Cima
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Department of Materials Science and Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts
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Brodovicz KG, McNaughton K, Uemura N, Meininger G, Girman CJ, Yale SH. Reliability and feasibility of methods to quantitatively assess peripheral edema. Clin Med Res 2009; 7:21-31. [PMID: 19251582 PMCID: PMC2705274 DOI: 10.3121/cmr.2009.819] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate methods to assess peripheral edema for reliability, feasibility and correlation with the classic clinical assessment of pitting edema. DESIGN Cross-sectional observational study. SETTING Large primary care clinic in Marshfield, Wisconsin, USA. PARTICIPANTS Convenience sample of 20 patients with type 2 diabetes and a range of edema severity, including patients without edema. METHODS Eight methods of edema assessment were evaluated: (1) clinical assessment of pit depth and recovery at three locations, (2) patient questionnaire, (3) ankle circumference, (4) figure-of-eight (ankle circumference using eight ankle/foot landmarks), (5) edema tester (plastic card with holes of varying size pressed to the ankle with a blood pressure cuff), (6) modified edema tester (edema tester with bumps), (7) indirect leg volume (by series of ankle/leg circumferences), and (8) foot/ankle volumetry by water displacement. Patients were evaluated independently by three nurse examiners. RESULTS Water displacement and ankle circumference had high inter-examiner agreement (intraclass correlation coefficient 0.93, 0.96 right; 0.97, 0.97 left). Agreement was inconsistent for figure-of-eight (0.64, 0.86), moderate for indirect leg volume (0.53, 0.66), and low for clinical assessments at all locations. Agreement was low for the edema testers but varied by the pressure administered. Correlation with the classic, subjective clinical assessment was good for the nurse-performed assessments and patient questionnaire. Ankle circumference and patient questionnaires each took 1 minute to complete. Other tools took >5 minutes to complete. CONCLUSIONS Water displacement and ankle circumference showed excellent reliability; however, water displacement is a time-consuming measure and may pose implementation challenges in the clinical and clinical trial environments. Patient-reported level and frequency of edema, based on an unvalidated questionnaire, was generally well correlated with the physician assessment of edema severity and may prove to be another reliable and accurate method of assessing edema. Additional study is needed to evaluate the validity and responsiveness of these methods.
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Affiliation(s)
- Kimberly G Brodovicz
- Department of Epidemiology, Merck Research Laboratories, North Wales, Pennsylvania 19454, USA.
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Aström KG, Abdsaleh S, Brenning GC, Ahlström KH. MR imaging of primary, secondary, and mixed forms of lymphedema. Acta Radiol 2001. [PMID: 11442467 DOI: 10.1034/j.1600-0455.2001.420412.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE To describe the pathological features and assess the diagnostic information of different MR sequences in patients with primary, secondary, and mixed (phlebo-, lipophlebo-, or lipolymphedema) forms of lymphedema of the lower leg. MATERIAL AND METHODS In 26 patients with clinical diagnoses of primary (n=10), pure secondary (n=4), mixed (n=9) and combined secondary and mixed forms of lymphedema (n=3), MR imaging was performed with coronal and axial T1 SE, T2 TSE, fat-suppressed (SPIR) T2 sequences and axial T1 SE after i.v. injection of Gd-DTPA. RESULTS In 24 patients there was a honeycomb pattern in the subcutis with a signal intensity corresponding to fluid (n=11), fibrosis (n=3), or both (n=10). Five patients with primary lymphedema showed subfascial fluid accumulation. Dermal edema was noted in 23 patients. Fat or edema components in the muscles were mostly seen in patients with phlebolymphedema. The honeycomb pattern was best seen on coronal T1 images, and fluid accumulations on axial SPIR-T2 images. Fibrosis was only assessible from the T2 TSE sequence. Gd-DTPA did not improve the diagnostic information. CONCLUSION For evaluation of lymphedema and its mixed forms, an axial T2-weighted SPIR sequence in conjunction with a coronal T1 SE sequence are sufficient.
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Affiliation(s)
- K G Aström
- Department of Radiology, University Hospital, Uppsala, Sweden
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