Bioreactance
What are the 5 key points when describing how Bioreactance technology works?
Name at least two validation studies and briefly describe them.
Hint: Clinical Deck - slide 35
4 non-invasive sensor pads are applied to the thorax, creating a "box" around the heart
a small electrical current of known frequency is applied across the thorax between the outer pair of sensors
a voltage signal is recorded between the inner pair of sensors
the flow of blood in the thorax introduces a time delay or phase shift in the signal
these phase shifts are correlated to known thermodilution CO with 65k patient samples in ICU/OR/cath lab
Heerdt 2011, Rich 2013, Squara 2007, Raval 2008
Why would I want to switch from my current practice of IRRT (SLEDD) to CRRT (CVVHDF) and what is your evidence?
Hint: KDIGO Reference and Principles of CRRT Slide 14.
KDIGO recommends CRRT for patients who require HD but are hemodynamically unstable.
Per Wendy:
Compared with intermittent hemodialysis, initiation of continuous renal replacement therapy in critically ill adults with acute kidney injury is associated with a lower likelihood of chronic dialysis. (Crit Care Med 2013; XX:00–00)
Why type of dynamic assessment (PLR or Bolus) was used in the KU study? FRESH?
KU=Both PLR and Fluid Bolus Challenges
FRESH= PLR Only
What defines AKI? Describe the KDIGO Stages of AKI. What resource (that was placed at your desk) can be used as a reference.
Hint: Principles of CRRT Slide 16
Review RIFLE page 5-6
What is the accuracy of Starling compared to a Swan?
Hint: Clinical Deck - slide 7
•3-way cath lab comparison of Starling System, Thermodilution & Indirect FICK
•CO as measured by Starling bioreactance technology and indirect FICK was more closely correlated than measurements obtained by Thermodilution
•Ability to detect >10% change
•Starling System: Sensitivity 88.9% / Specificity 100%
Swan Ganz: Sensitivity 88.9% / Specificity 100What is the best study to reference with regards to fluid overload/removal when comparing IHD/CRRT and what does it imply?
Hint: Principles of CRRT Slide 17.
Fluid overload questions can be talked about using PICARD study Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury - PubMed (nih.gov).Slow and steady wins the race.
What is the sensitivity and specificity of a passive leg raise and what studies can you reference?
Hint: Clinical Deck - slide 16
Monnet X, Marik P, Teboul JL. Passive leg raising for predicting fluid responsiveness: a systematic review and meta-analysis. Intensive Care Med. 2016 Dec;42(12):1935-1947.
N=995
FR: 54%
ROC 0.95
Sensitivity 0.85
Specificity 0.91
Bentzer P et al. Will this hemodynamically unstable patient respond to a bolus of intravenous fluids. JAMA 2016; 316(12), 1298.
N=2260
FR: 50%
Sensitivity 0.88
Specificity 0.97
According to KDIGO, what stage should RRT be considered?
Hint: KDIGO Reference page 7-8
Stage 2
T/F The Fedora Trial (mentioned in the sales and clinical decks) demonstrates the Starling monitor's capabilities and outcomes in the operating room?
Hint: Clinical Deck - slide 15
False. FEDORA used an oesophageal Doppler monitor. However, they looked at stroke volume guided fluid and had similar results as FRESH.
What are the benefits of doing pre versus post replacement solutions? Hint: Reference slide slide 40
For Pre the benefit is a diluted blood going into the filter which decrease hematocrit and can potentially help with clotting. The disadvantage of going with Pre is the 17% less clearance of solutes. For Post the benefit is better clearance of solutes having not diluted the blood. With Post you will get a higher level of hematocrit in the filter which could lead to higher levels of clotting unless you are therapeutically anti-coagulated.
According to the Bentzer study, what parameter performed the best to indicate if a patient was fluid responsive?
Hint: Clinical Deck - slide 8
SV change performed best (Sens 88%/Spec 92%)
What is the recommended delivering dosage for CRRT? Hint: KDIGO Reference page 18
How are CRRT prescriptions calculated? What is it called?
Hint: Principles of CRRT Slide 46-47
Where do you find this number on the screen?
According to KDIGO, the best evidence to date supports an "effluent dose" at a minimum of 20-25 ml/kg/hr.
All scales are added up plus PFR rate, and then divided by the entered weight.
The prescribed dosage is the "effluent dose" on the main prescription screen (depends on Flex/Max for location).
What study demonstrates a statistically significant improvement in mortality with the Starling Monitor.
Trick Question! There isn't one (not yet anyway).
While FRESH is not statistically significant there is a a positive "signal."
Why do I need a solution that contains Phosphate?
Most critically ill patients requiring CRRT have hyperphosphatemia and within 24 hours on therapy could have hypophosphatemia. There is zero concentration of Phosphate is dialysate and therefore diffusive clearance will remove significant phosphate molecules.
What does it mean to be fluid responsive? What does it mean to not be fluid responsive?
Hint: Clinical Deck - slide 19
Bonus Points: Where can you find a technical definition of what a delta SVI >10% predicts?
≥ 10% ∆ SVI = fluid responsive
•Additional fluid will most likely improve perfusion
<10% ∆ SVI = NOT fluid responsive
•Additional fluid is unlikely to improve perfusion.
Neither indicate if a patient "needs" fluid or not.
Bonus Point: The dynamic assessment card has a reference that describes a delta SVI of 10% or more indicates that CO is likely to improve by 15% with the next 500cc of fluid
What are two of the best Baxter tools to provide to customers to support information on AKI, RRT Staging, CRRT recommendations, and dosing?
Hint: These can be ordered in Diamond.
You can order a KDIGO booklet and dosing card in Diamond.
What are the Starling monitor limitations or contraindications and where can you find them?
In the IFU on vablet.
FDA approved for adult population and requires pulsatile flow.
Most of the clinical situations and patient conditions listed below may impact absolute values but should not affect device responsiveness and sensitivity/specificity to assess directional hemodynamic changes.
Examples of conditions that can influence reported Cardiac Output (CO), influence monitor accuracy, or result in suboptimal signal quality are shown below. 1. Severe aortic insufficiency: The regurgitation fraction associated with severe cases of aortic insufficiency may result in overestimation of the net forward CO. That is because the Starling measures the ejection but does not subtract the backward regurgitation that takes place during diastole.
2. Severe anatomic abnormalities of the thoracic aorta such as a large synthetic aortic graft, large aortic aneurysm or large aortic dissection can impact the accuracy or performance of hemodynamic parameters. The abnormality has to be large in order to have a meaningful impact on monitor accuracy.
3. External pacemakers and internal pacemakers with unipolar electrodes Use caution in monitoring patients with external pacemakers, and patients with relatively older models of internal pacemakers which utilize unipolar electrodes. Some external pacemakers and unipolar internal pacemakers can add electrical artifact to the Starling Bioreactance signal. Note It is possible to completely mitigate It is possible to completely mitigate or significantly alleviate the problem by placing the Starling Sensor 2.5 inches (approximately 6 cm) or more away from the external pacemaker percutaneous lead. Unipolar internal pacemakers are rarely used today.
Patient Populations in Which the Starling Monitor Has Not Been Tested
Patients with congenital heart disease associated with complex intra-cardiac shunts.
Patients with Continuous Flow LVADs: The Starling technology works by detecting pulsatile changes in aortic blood volume. With a continuous flow LVAD, by definition, there are little if any pulsations unless the heart itself ejects. Therefore, use of the Starling device in these patients is not recommended.
What is the evidence that shows that CVVH or CVVHDF is superior to CVVHD alone in sepsis patients?
To date there is conflicting evidence and differing opinions even with KOL.
Name at least two clinical entities who endorse dynamic assessments?
Hint: Sales Deck - slide 8
ESCICM, CMS, SSC, WHO
KDIGO discusses anticoagulation options including heparin and regional citrate. What is your opinion on the different anticoagulation options?
TRICK QUESTION! We don't have opinions and field any questions related to regional citrate to medical affairs because it is off-label. The KDIGO Reference tool and an email to Rick DaSilva may provide support for customers with this question.