Ultrafiltration as a therapy option for diuretic resistance inpatient outpatient case studies
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Beth Davidson DNP, ACNP, CCRN Kristi Hayes MSN, FNP St. Thomas Hospital Nashville, TN PowerPoint PPT Presentation


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Ultrafiltration as a Therapy Option for Diuretic Resistance: Inpatient & Outpatient Case Studies. Beth Davidson DNP, ACNP, CCRN Kristi Hayes MSN, FNP St. Thomas Hospital Nashville, TN. Objectives. Review the epidemiology and pathophysiology of diuretic-resistant, acute heart failure

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Beth Davidson DNP, ACNP, CCRN Kristi Hayes MSN, FNP St. Thomas Hospital Nashville, TN

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Ultrafiltration as a therapy option for diuretic resistance inpatient outpatient case studies

Ultrafiltration as a Therapy Option for Diuretic Resistance: Inpatient & Outpatient Case Studies

Beth Davidson DNP, ACNP, CCRN

Kristi Hayes MSN, FNP

St. Thomas Hospital

Nashville, TN


Objectives

Objectives

Review the epidemiology and pathophysiology of diuretic-resistant, acute heart failure

Identify volume overload treatment options

Review/discuss case studies of diuretic-resistance and use of ultrafiltration for volume removal


Epidemiology of heart failure hf

Heart failure is a major public health problem resulting in substantial morbidity and mortality

Major cost-driver of HF is high incidence of hospitalizations

JCAHO has initiated quality care indicators for hospitalized HF patients

CMS reimbursement for readmission < 30 days = $ 0

Epidemiology of Heart Failure (HF)


Beth davidson dnp acnp ccrn kristi hayes msn fnp st thomas hospital nashville tn

Decompensated

Heart Failure

Insult

Cardiac Dysfunction

LV Remodeling

Neurohormonal

Activation

 RAAS/SNS

 Catecholamine

 Endothelin

Hemodynamic

Decompensation

 Preload

 Afterload

↓ Cardiac Output

FluidOverload Symptoms

Morbidity

Death

Renal Vasoconstriction/

Fluid Retention


Acc aha guidelines management of fluid status

ACC/AHA Guidelines:Management of Fluid Status

Patients should not be discharged from the hospital until a stable and effective diuretic regimen is established, and ideally, not until euvolemia is achieved

Patients who are sent home before these goals are reached are at high risk of recurrence of fluid retention and early readmissionbecause unresolved edema may itself attenuate the response to diuretics


Diuretics

Diuretics

  • Diuretics…

More diuretics...

Still more diuretics…

Current “Standard of Care”


Change in weight during hospitalization outcomes with standard care

Change in Weight During HospitalizationOutcomes with Standard Care

Evidence of Incomplete Relief From Congestion

Nearly 50% of ADHF patients discharged with weight gain or losing less than 5 lbs

27%

30

26%

25

20

Enrolled Discharges(%)

13%

15

16%

7%

6%

10

3%

2%

5

0

(<-20)

(–20 to –15)

(-15 to –10)

(–10 to –5)

(–5 to 0)

(0 to 5)

(5 to 10)

(>10)

Change in Weight (lbs)


Beth davidson dnp acnp ccrn kristi hayes msn fnp st thomas hospital nashville tn

Outcomes with Standard Care

Hospital Readmissions

Mortality

50%

50%

33%

37%

20%

12%

30

Days

3

Months

6

Months

30

Days

12

Months

5

Years

Patients have persistently high event rates despite use of evidence-based therapies…


Beth davidson dnp acnp ccrn kristi hayes msn fnp st thomas hospital nashville tn

CARDIACFAILURE

Left Ventricular Dysfunction

Loop Diuretic Inhibition of Macula Densa

Cardiac Remodeling and Fibrosis

Increased Renin-Angiotensin

Increased

Aldosterone

Effect of Loop Diuretics on RAAS in Cardiac Failure


Current options may have undesirable clinical impacts

Current Options May Have Undesirable Clinical Impacts

  • Favorable aspects of diuretic therapy

    • Increases urine output; reduces total body volume

  • Adverse aspects of diuretic therapy

    • Direct activation of renin-angiotensin-aldosteronesystem

    • Enhanced myocardial aldosteroneuptake

    • Loss of K, Mg, Ca, secondary myocyte Ca loading

    • Indirect reduction of cardiac output

    • Increased total systemic vascular resistance

    • Reduced natriuresisand GFR

    • Associated with increased morbidity and mortality


Diuretics and adhf

Diuretics and ADHF

14):39-42.

  • No consensus dosing guidelines

  • No common definition of diuretic resistant

  • No long-term studies of diuretic therapy for the treatment of heart failure

  • No outcomes data regarding morbidity and mortality


Diuretic resistance

Diuretic Resistance

Can be described as a clinical state in which the diuretic response is diminished or lost before the therapeutic goal of relief from edema has been reached

Affects 20%–30% of patients with HF


Diuretic resistance two types

Diuretic Resistance: Two Types

  • “Braking” phenomenon

    • A decrease in response to a diuretic after the first dose has been administered

  • Long-term tolerance

    • Tubular hypertrophy to compensate for salt loss


Diuretic therapeutic dilemma

Diuretic Therapeutic Dilemma

Diminished renal function and concurrent sodium and water retention in ADHF presents a therapeutic dilemma with regard to sub-maximal diuretic therapy

Fluid removal by ultrafiltration may be recommended in this clinical setting


Beth davidson dnp acnp ccrn kristi hayes msn fnp st thomas hospital nashville tn

What is Aquapheresis?

  • Method to safely achieve euvolemia

  • Simplified form of ultrafiltration

  • Inpatient or outpatient settings

    • ICU, CCU, MICU, telemetry, step-down, observation, ED, outpatient clinics

  • Peripheral or central venous access

    • Flexible access sites and catheters

  • Diverse physician prescription

  • Highly automated operation

  • No clinically significant impact on electrolyte balance, blood pressure, or heart rateor heart rate*


Fluid removal by ultrafiltration

Fluid Removal by Ultrafiltration

  • Ultrafiltration can remove fluid from the blood at the same rate that fluid can be naturally recruited from the tissue

  • The transient removal of blood illicits compensatory mechanisms, termed plasma or intravascular refill (PR), aimed at minimizing this reduction

Interstitial

Space (edema)

Na

P

H2O

Na

K

UF

K

PR

P

Vascular

Space

Na

Vascular

Space

Na


The euphoria study

The EUPHORIA Study

  • Single center, prospective study, 20 patients

  • Initial UF within 12 hours of hospitalization and before any significant administration of IV diuretics and/or vasoactive drugs

  • Results

    • Removed an average of 8.6 liters of fluid

    • 60% of patients were discharged in ≤ 3 days

    • Average hospitalization was 3.7 days


The euphoria study1

The EUPHORIA Study

  • Rehospitalization

    • In the three months preceding ultrafiltration:

      10 hospitalizations in 9 patients

    • After ultrafiltration:

      1 readmission for ADHF within 30 days


The unload study

The UNLOAD Study

  • 200 patients (100 each arm) randomized, multi-center study comparing ultrafiltration versus standard care for acutely decompensated patients

  • Superior salt & water removal/weight loss

  • At 48 hours, ultrafiltration demonstrated

    • 38% greater weight loss

    • 28% greater net fluid loss

  • At 90 days, reduced readmissions

    • 50% reduction in re-hospitalization episodes

    • 63% reduction in total re-hospitalized days

    • 52% reduction in emergency department or clinic visits


Acc aha guidelines class iia level of evidence b

ACC/AHA Guidelines: Class IIa, Level of Evidence B

I IIa IIb III

B

Ultrafiltration is reasonable for patients with refractory congestion not responding to medical therapy

Aquapheresis is now ranked HIGHER in the

Level of Evidence than:

- salt restriction

- strict I/Os

- higher doses of loop diuretics

- addition of a second diuretic

- continuous infusion of a loop diuretic

- vasodilators – IV nitroglycerin, nesiritide

- IV inotropes

All of these are Level of Evidence: C


Case study

Case Study

  • 68 yo WM

  • Diastolic heart failure

  • Ischemic heart disease

    • CAB 4/06

  • HTN

  • Afibrillation/flutter

  • Anemia

  • Hospitalized every

    6 months for exacerbation


Case study inpatient therapy

Case Study: Inpatient Therapy

  • Inpatient ultrafiltration – January 2010

    • Access issues – extended length catheter (ELC)

    • Creatinine 1.5 2.9 after 48 hrs of treatment

      • Creatinine 1.6 at discharge

    • Therapy/ACEI discontinued

    • Diuresed with IV lasix continuous infusion

    • LOS = 5 days

    • Net volume loss = 7 kgs


Case study outpatient therapy

Case Study: Outpatient Therapy

  • 1st treatment- 2/22/10

    • ELC catheter

    • 1850 cc ultrafiltrate over 7 hrs

    • Wt loss = 2 lbs

    • Serum Cre = 1.8 pre and at termination of therapy

    • Hct 29 – sent home with hemoccult cards

      • Positive x 3- referred to PCP – no follow-up


Case study outpatient therapy1

Case Study: Outpatient Therapy

  • 2nd treatment – 3/26/10

  • ELC catheter and 18 g peripheral IV

    • Access issues!

  • 2130 ultrafiltrate over 6.5 hrs

    • Also treated with Lasix 240mg IV due to loss of time waiting for access

  • Serum Cre = 1.7 pre and post termination of therapy

  • Hct 26 - referred to Hematology


Saint thomas hospital inpatient outcomes

Saint Thomas Hospital:Inpatient Outcomes

54 UF treatments from 5/1/08 – 6/1/10

Average treatment time = 37 hours, 28 minutes

Average fluid removal = 6.15 liters/circuit

Minimal adverse events

9 episodes of worsening renal insufficiency

No significant electrolyte disturbances

No significant hypotension

1 asymptomatic, small apical pneumothorax

6 minor bleeding episodes – epistaxis, line insertion site, generalized “oozing”


Saint thomas hospital inpatient outcomes1

Saint Thomas Hospital:Inpatient Outcomes

  • Readmissions < 30 days

    • 1 re-admitted with LOC changes

    • 2 discharged to hospice

      • ultrafiltration for palliation

    • 1 patient, 5 re-admissions

      • now on dialysis for volume control

      • no readmits since dialysis except for recent hip fracture

    • 1 expired within 90 days of readmission

    • 1 patient, 2 re-admissions

      • suspect non-compliance – eating Whopper at discharge!


Saint thomas hospital outpatient outcomes

1st outpatient treatment – January 19, 2010

13 treatments – 7 pts

avg treatment time 5.79 hrs

avg volume removal 1.49 L

1 repeated hospitalization

now on peritoneal dialysis

1 deceased

1 ARF

patient did not follow

medication discharge

instructions

Effective in keeping pts out of hospital > 30 days

Need more data

Pt satisfaction and QOL are most important!

Saint Thomas Hospital:Outpatient Outcomes


Advanced heart failure clinic saint thomas hospital

Advanced Heart Failure ClinicSaint Thomas Hospital


Beth davidson dnp acnp ccrn kristi hayes msn fnp st thomas hospital nashville tn

Another satisfied customer…


Challenges and opportunities for improvement

Challenges andOpportunities for Improvement

  • Early identification of patients that could benefit from outpatient therapy to decrease readmission within 30 days

  • Process improvement – timely, efficient IV access to allow faster initiation of therapy

  • Patient education – medications, line care, follow-up appointments, etc…

  • Anticoagulation – preserve integrity of circuit


Any questions

Any questions?


Contact information

Contact Information

Beth Davidson DNP, ACNP

[email protected]

Kristi Hayes MSN, FNP

[email protected]


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