2020_Measurement of Vascular Access by OCM 03_Final

Educational Symposium: Measurement of Vascular Access by OCM ศ.นพ.ขจร ตีรณธนากลุ ภาควิชาอายรุ ศาสตร์ คณะแพทยศาสตร์ โรงพยาบาลจฬุ าลงกรณ์ และ จฬุ าลงกรณ์มหาวิทยาลยั Hand-out Nursing Management for Renal care base on Knowledge & Education 17th October 2020

Vascular access and OCM • ESKD Life-Plan • Vascular Access Flow Dysfunction Screening • AV Access Flow Dysfunction Monitoring • Role of OCM • AV Access Flow Dysfunction Surveillance • Monitoring vs. Surveillance • Ultrasound-dilution method • OCM method Hand-out • Hb dilution method • Conclusion

Vascular Access as a part in ESKD Life-Plan “the right access in the right patient, at the right time, for the right reasons” P-L-A-N : Patient Life-plan and their Access Needs ViP ACCeS plans: 1) Vessel important Preservation plan 2) Access Creation plan 3) Contingency plan 4) ESKD Succession plan Am J Kidney Dis. 2020;75(4)(suppl 2):S1-S164.

Vascular access and OCM • ESKD Life-Plan • Vascular Access Flow Dysfunction Screening • AV Access Flow Dysfunction Monitoring • Role of OCM • AV Access Flow Dysfunction Surveillance • Monitoring vs. Surveillance • Ultrasound-dilution method • OCM method Hand-out • Hb dilution method • Conclusion

AV Access Flow Dysfunction Screening Physical Examination (Monitoring) Surveillance Hand-out

AV Access Flow Dysfunction Screening Physical Examination (Monitoring) Surveillance • include inspection , palpation for pulse and thrill, and auscultation ลักษณะทต่ี รวจ ภาวะปกตสิ มบรู ณ์ ภาวะ stenosis รุนแรง Pulse soft , easily compressible pulse firm, strong pulse (AVF) (AVF) Pulse abruptly decrease downstream to the stenosis (AVF) Water-hammer pulse (AVG) Thrill continuous thrill discontinuous thrill หรือ คลาไดล้ กั ษณะของ pulse แทน Bruit continuous low pitched discontinuous high pitched ได้ยนิ เฉพาะใน systolic phase เทา่ นั้น

AV Access Flow Dysfunction Screening Physical Examination (Monitoring) Surveillance • Access flow: direct measurement (for AVF, AVG) – Doppler (duplex) ultrasound – Magnetic resonance imagine • Access flow: indirect measurement (for AVF, AVG) – Ultrasound (saline) dilution – OCM Method – Manual Hb dilution – Temperature dilution – Glucose infusion • Static venous pressure (for AVG) • Access recirculation (for AVF)

AV Access Flow Dysfunction Screening Physical Examination (Monitoring) Surveillance • Access flow: direct measurement (for AVF, AVG) – Doppler (duplex) ultrasound – Magnetic resonance imagine • Access flow: indirect measurement (for AVF, AVG) – Ultrasound (saline) dilution – OCM Method – Manual Hb dilution – Temperature dilution – Glucose infusion • Static venous pressure (for AVG) • Access recirculation (for AVF)

AV Access Flow Dysfunction Screening Physical Examination (Monitoring) Surveillance

Vascular access and OCM • ESKD Life-Plan • Vascular Access Flow Dysfunction Screening • AV Access Flow Dysfunction Monitoring • Role of OCM • AV Access Flow Dysfunction Surveillance • Monitoring vs. Surveillance • Ultrasound-dilution method • OCM method • Hb dilution method • Conclusion

AV Access Flow Dysfunction Monitoring Physical Examination (Monitoring) Surveillance • Clinical Indicators Am J Kidney Dis. 2020;75(4)(suppl 2):S1-S164.

AV Access Flow Dysfunction Monitoring Physical Examination (Monitoring) Surveillance • Clinical Indicators : ↓ spKt/V - No RCT evidence supporting the use of Kt/V in the prediction of stenosis and thrombosis - Monthly monitoring spKt/V (or even longer) have limited sensitivity and specificity for vascular access dysfunction - The role of frequent spKt/V monitoring by online monitoring (such as OCM) would be better than monthly monitoring

Determination of Kt/V • Formal UKM method • Empirical estimation method (natural logarithm) • Online real-time monitoring  Online urea monitoring  Online ultraviolet (UV) absorbance monitoring  Online conductivity clearance monitoring : OCM • Direct quantitation

Determination of Kt/V : Conductivity clearance  Online conductivity clearance monitoring : Such as - OCM (Online Clearance Monitoring)

Determination of Kt/V : Conductivity clearance  Online conductivity clearance monitoring • อาศยั หลกั การว่า ค่าสมั ประสิทธ์ิการกรอง (K) ของโซเดียม และยเู รียมีค่าใกล้เคียงกนั • การศึกษาพบว่าค่า urea clearance และ electrolyte (or Na) clearance มีค่าใกล้เคียงกนั และมีความสมั พนั ธก์ นั เชิง เส้นตรง

Determination of Kt/V : Conductivity clearance  Online conductivity clearance monitoring • การวดั ค่าการนาไฟฟ้าในน้ายา dialysate ทงั้ ขาเข้าและ ขาออกจาก dialyzer และแปลงกลบั เป็นค่าความเข้มข้น ของเกลือ NaCl กจ็ ะสามารถทาการคานวณอตั ราการ ขจดั ยเู รียในน้ายา dialysate ได้ทางอ้อม • เครอ่ื งที่ใช้หลกั การนี้ เช่น เครอื่ ง on-line clearance monitor (OCM) ของบริษทั Fresenius

Determination of Kt/V : Conductivity clearance  Online conductivity clearance monitoring K? CDi CDo ?CBi

Determination of Kt/V : Conductivity clearance What is Kt/V? Treatment time (t) Ionic (~Urea) Urea distribution volume (V) Clearance (K) Kt/V = Example: = 1,36 245 ml/min * 300 min 54.000 ml

Determination of Kt/V : Conductivity clearance Determination of “V“ by Anthropometry such as Watson formula Determination of “V“ by bioelectrical impedance device such as BCM (Body Composition Monitoring)

Bioelectrical impedance (BIA) :BCM BCM

Determination of Kt/V : Conductivity clearance On-line clearance monitor (OCM) : Precision of Kt/V by OCM vs. Gold standard

AV Access Flow Dysfunction Monitoring • Clinical Indicators : ↓spKt/V by OCM

Vascular access and OCM • ESKD Life-Plan • Vascular Access Flow Dysfunction Screening • AV Access Flow Dysfunction Monitoring • Role of OCM • AV Access Flow Dysfunction Surveillance • Monitoring vs. Surveillance • Ultrasound-dilution method • OCM method • Hb dilution method • Conclusion

AV Access Flow Dysfunction Screening Physical Examination (Monitoring) Surveillance • Access flow: direct measurement (for AVF, AVG) – Doppler (duplex) ultrasound – Magnetic resonance imagine • Access flow: indirect measurement (for AVF, AVG) – Ultrasound (saline) dilution – OCM Method Criteria for access flow dysfunction – Manual Hb dilution – Temperature dilution - <500 mL/min (AVF) - <600 mL/min (AVG) – Glucose infusion - >1000 mL/min +↓25% over 4 mo • Static venous pressure (for AVG) • Access recirculation (for AVF)

Monitoring vs. Surveillance: Thrombosis Limited data from RCTs AVF: Favor surveillance with pre-emptive correction AVG: Not significant Overall: Favor surveillance with pre-emptive correction

Monitoring vs. Surveillance: Access loss Limited data from RCTs AVF: Favor surveillance with pre-emptive correction AVG: Not significant Overall: Not significant

Monitoring vs. Surveillance: Other outcome Limited data from RCTs Surveillance compared with monitoring - Mortality: not different - Infection : not different - Angiogram: more frequent - Hospitalization: lesser - Cather insertion: lesser

Vascular access surveillance Incidence of thrombosis 40 35 Vascular Access Monitoring by HD01 in King Chulalongkorn Memorial Hospital 30 Incidence (%) 25 20 14.06 15 10 7.14 3.13 0 0 5 2000 2001 2002 2003 0 1999 Year After surveillance program Tiranathanagul K , Tungsanga K, Chulalongkorn Hospital

AV Access Flow Dysfunction Screening Physical Examination (Monitoring) Surveillance

AV Access Flow Dysfunction Does not recommend pre-emptive Consider pre-emptive angioplasty angioplasty or surgical intervention of AV access with stenosis, of AV access with stenosis, not associated with consistently associated with clinical indicator persistent clinical indicators

AV Access Flow Dysfunction

AV Access Flow Dysfunction Surveillance Monitoring (Control group) vs. Monitoring+Surveillance (Surveillance group) : higher stenotic confirm diagnosis

AV Access Flow Dysfunction Surveillance Monitoring (Control group) vs. Monitoring+Surveillance (Surveillance group) : reduce thrombotic events

AV Access Flow Dysfunction Surveillance Current role of access surveillance : add-on PE monitoring - In case of monitoring is not clear - Access surveillance could detect stenosis more sensitive than monitoring alone and lead to identify high-risk patient that need close attention for future clinical significant stenosis - Pre-emptive intervention should not depend only on surveillance data - So, method should not be expensive

Vascular access and OCM • ESKD Life-Plan • Vascular Access Flow Dysfunction Screening • AV Access Flow Dysfunction Monitoring • Role of OCM • AV Access Flow Dysfunction Surveillance • Monitoring vs. Surveillance • Ultrasound-dilution method • OCM method • Hb dilution method • Conclusion

AV Access Flow Dysfunction Surveillance • Access flow : Ultrasound (saline) dilution Criteria for access flow dysfunction - <500 mL/min (AVF) - <600 mL/min (AVG) - >1000 mL/min +↓25% over 4 mo

AV Access Flow Dysfunction Surveillance • Access flow : Ultrasound (saline) dilution

AV Access Flow Dysfunction Surveillance • Access flow : Ultrasound (saline) dilution

Vascular access and OCM • ESKD Life-Plan • Vascular Access Flow Dysfunction Screening • AV Access Flow Dysfunction Monitoring • Role of OCM • AV Access Flow Dysfunction Surveillance • Monitoring vs. Surveillance • Ultrasound-dilution method • OCM method • Hb dilution method • Conclusion

AV Access Flow Dysfunction Surveillance Vascular access monitoring using OCM Determination of online clearance - Normal position - Reversed position This recirculation is inversely proportional to VA flow rate

AV Access Flow Dysfunction Surveillance Vascular access monitoring using OCM 1. ตอนเรมิ่ hemodialysis ต่อวงจรแบบปกติ เปิด BF 300ml/min ตลอดการวดั 2. เขา้ mode OCM 4. บนั ทกึ คา่ clearance ทเ่ี ครอ่ื งอ่านคงทแ่ี ลว้ เอาไว้ ถอื เป็นคา่ Knorm 5. สลบั สาย A กบั V 6. รอ OCM อา่ นคา่ clearance ใหม่ (ประมาณ 20 นาท)ี บนั ทกึ คา่ clearance เอาไว้ ถอื เป็นคา่ Krev 8. คานวณคา่ Access flow จาก OCM (QaOCMT)ดว้ ยสตู ร Qa = (D-QUF ) x Drev D - Drev

AV Access Flow Dysfunction Surveillance Vascular access monitoring using OCM Correlation between OCM Method and HD03 (Ultrasound-dilution method)

AV Access Flow Dysfunction Surveillance Vascular access monitoring using OCM Precision of access flow by OCM vs. Gold standard

Vascular access and OCM • ESKD Life-Plan • Vascular Access Flow Dysfunction Screening • AV Access Flow Dysfunction Monitoring • Role of OCM • AV Access Flow Dysfunction Surveillance • Monitoring vs. Surveillance • Ultrasound-dilution method • OCM method • Hb dilution method • Conclusion

AV Access Flow Dysfunction Surveillance Novel simple Hb dilution technique

AV Access Flow Dysfunction Surveillance Novel simple Hb dilution technique Correlation between Hb dilution technique and HD01

Vascular access and OCM • ESKD Life-Plan • Vascular Access Flow Dysfunction Screening • AV Access Flow Dysfunction Monitoring • Role of OCM • AV Access Flow Dysfunction Surveillance • Monitoring vs. Surveillance • Ultrasound-dilution method • OCM method • Hb dilution method • Conclusion

Conclusion • The most important VA flow dysfunction screening tool is monitoring by physical examination and clinical indicator including Kt/V • OCM could be used for frequent Kt/V monitoring • Surveillance could be add-on clinical monitoring for early detection of VA flow stenosis • OCM could be easily applied to indirect measurement of VA flow. This method are non-invasive and no additional cost. The flow value from OCM method was comparable with gold-standard ultrasound dilution method (need expensive machine)

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