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Detection of Renal Blood Flow

Abnormalities
in Septic and Critically Ill
Patients Using a Newly Designed
Indwelling Thermodilution
Renal Vein
Catheter*
Matthew
Anthony

Brenner,
M.D.;
Gary
L. Schaer,
F. Suffredini,
M.D.;
andJoseph

M.D.;
Douglas
L. Mallory,
E. ThrriIIO,
M.D.

To evaluate
alterations
in renal
blood flow in sepsis-induced
renal
failure,
we developed
and studied
a percutaneously
placed
thermodilution
renal blood flow catheter
in eight
critically
ill patients.
Para-aminohippurate
extraction
coefficients
were decreased,
supporting
the need for renal
vein sampling
to determine
C,
in sepsis. Thermodilution
and CPAH methods
correlated
strongly,
confirming
the reliability
of this thermodilution
method,
Renal
vascular
resistance,
an indicator
ofrenal
vascular
function,
remained
unchanged
throughout
the bouts of sepsis
The fraction
of
total
body
arterial
blood
flow going to the kidneys
rose
significantly
during
recovery
from sepsis. Glomerular
flutration
rate, which
was reduced
in four of seven septic
patients,
correlated
with the fraction
of total blood
flow
going
to the kidneys.
These
results
suggest
that
renal

eptic

shock

complicating

is the leading
death
in intensive
tion

develops

severe

frequently

in

hemodynamic

patients

increased
infection

abnormalities

potentially
nephrotoxic
ute to the development
mortality
of sepsis-induced

of renal

function

nism
injury

of acute
and

may

ology

ofrenal

*Fmm

the

National

Critical

in critically

play

failure
Care

the

use

of

a central

role

leading
to
the preser-

ill patients.

in renal
blood
flow are
renal
failure
in animal

Alterations

is

vasoactive
agents
may contribof renal
failure.
The
high
renal
failure
underscores

the need
to understand
the mechanisms
renal
failure
and to develop
methods
for
vation

and

mortality.3
with
the

and

a major
models

in the

in septic

patients.

Medicine

Department,

abnormalities

shock.

Our

study

dysfunction
blood

may

flow

alterations

Clinical

Institutes
in part

Center,

ofHealth,
Bethesda,
MD.
Presented
at the annual
meeting,
American
Federation
for
Clinical
Research,
San Diego,
CA, May 1987,
and the 16th Annual
Educational
and Scientific
Symposium,
Society
of Critical
Care
Medicine,
Anaheim,
CA, May 1987.
Published
in abstract
form in
Clin Bes 1987;34:884a,
and Crit Care Med 1987;i5:435.
Manuscript
received
October
26; revision
accepted
January
31,
1990.
Reprint
requests:
Dr. Brenner,
Bldg 53, Pan 199, Pulmonary
and
Critical
Care,
UC/MC,
101 City Drive
South,
Orange,
CA 92714

170

Downloaded From: http://journal.publications.chestnet.org/ on 03/22/2016

may
demonstrates

occur

during

be

during
septic
sepsis-induced
renal
ranges
of total renal
(Chest
1990; 98:170-79)

occurring

that

despite

normal

shock.

CC (in vitro)computation
constant
for in vitro
fluid
flow;
CPAH=clearance
ofpara-aminohippurate;
CIcorrection
factar for in vitro fluid flows (CC/[60JV1);
ERPFeffecdve
renal
plasma
flow;
GFRglomenilar
filtration
rate; PAll
paraaminohippurate;
RBF
renal
blood
flow; RVR
renal
vascular
resistance;
Thtemperature
of blood; Tltemperature
of
injectate;
VIvolume
ofinjectate;
Up
urinary
PAH concentration;
V
= urine volume;
Art,
arterial
PAll
concentration; Ven,venous
PAH concentration;
Uurinary
inulin
concentrafion
Vurine
volume;
Art,.arterial
inulin
concentration

events
blood

blood

flow

may

be

sufficient

to initiate

the

which
lead to renal failure.7
The role of altered
flow in the pathogenesis
of renal dysfunction
in

humans

remains

limitations

difficult

associated

to characterize

with

the

because

measurement

of

of renal

flow during
sepsis.
Although
urine
output
is
used clinically
to evaluate
shock,
urine
flow does not
closely
correlate
with
renal
blood
flow. A standard
method
of estimating
total renal blood
flow in healthy
blood

persons
is the CPAH ,8 Creater
than 90 percent
of PAH
is removed
from the circulation
during
a single passage
through
the kidneys
in normal
humans.
This almost
complete

mechaof renal

pathophysi-

Brief

vascular

in renal

infections

organ
failure
and
Renal dysfunc-

septic

associated
with a substantially
The
severity
of the underlying
resultant

bacterial

cause
of multiple
care unit pats2

M.D.;

removal

of PAH

results

accurately
estimate
overall
renal
sepsis
reduces
PAH extraction
mechanisms.&la

This

decrease

ing sepsis
thus introduces
blood
flow determination.

in clearances

that

blood
flow. However,
through
a variety
of
in PAH

extraction

serious
errors
Additionally,

dur-

in the renal
the time
re-

quired
for equilibration
of indicator
levels
for the
clearance
method
measurements
limits the use of CPAH
in the intensive
care unit where
frequent
physiologic
changes

require

rapid,

reproducible

methods

of meas-

1 1, 12, 1922

We
which

have
developed
a specially
is placed
percutaneously
Renal

Blood Flow Abnormafitles

m Septic

shaped
catheter
under
fluoroscopic
and Critically

III (Brenner

et a!)

/(0cm

Injectate
Opening

Port
(Opening

Convex

on

Portion

of

Catheter

Curve(

FIGURE
1. Design
of RBF
catheter
used
in present
study.
The
catheter
has a 180#{176}
bend
in the catheter
2 cm from the distal
end
designed
to curl the tip into the renal
vein orifice,
and a 45#{176}
bend
6 cm from the distal
tip to allow access
to the renal vein.

guidance

into

the

renal

vein.

The

placement

catheter
in the renal
vein allows
direct
renal venous
blood,
and determinations
ovenous

PAH

accurate
results

extraction

can

calculations
of our experience

be

of the

sampling
of
of the arteri-

performed,

allowing

of CPA,, We report
herein
the
with this renal vein catheter.
.

Further
development
of such techniques
should
vide a means
for measuring
serial thermodilution
renal

CPAH

blood

flow

measurements

proand

in critically

ill

patients.
MATERIALS

Catheter

AND

METHODS

Design

The

catheter

(Critikon

was

designed

Corporation,

polyvinylchloride
a rapid

with

Tampa,

catheters,

response

FL):
with

thermistor

the
5-F,

100cm

with

following
double

standard

catheter

is fashioned

with

a i80

bend

allowing

the

tip to curl

within

bend

6 cm

tip allows

access

the

distal

containing

Edwards

end,

from

radiopaque

ofusablelength,

The

catheter

specifications

lumen,

connectors.

2 cm

from

the

renal

to the

the

distal

vein.

renal

A 45#{176}

vein

(Fig

1).

Catheter

Calibration

vitro flow experiments


were
reproducibility
of the thermodilution
in

of

the

catheter

determined
rates

was

against

a range

a plastic

tubing

constants

were

Patient

( seven

and

of standard

system

the

accuracy

flow

(Appendix

The

computation

catheter-determined

determined

November
with

and

accuracy

constants

were

thermodilution

rates

of fluid

flow

pumped

1). Thermodilution

through

computation

for the catheter.

1985

septic

concurrent

medical

protocol

Review

Board
informed

Septic

shock

to April

shock)
care

was

entry

>38#{176}C, hypotension

eight
serial

hemodynamic
unit

at the

approved

at the
written

1987,

underwent

systemic

intensive

study
gave

to verify
measurements.

Population

From
and

validated

by comparing

used

National

by

National
the

critically
function

function

studies

Institutes

Institutional

Institutes

ill patients

renal

in

of Health

the
. The

Human

Research

and

all patients

of Health

FICuIIF:

studies

consent.
criteria
(mean

were

defined

arterial

(a) temperature

as either:
pressure

<60

mm

Hg,

or

2. (]p7)er:
Diagran
repres(IIting
tle in tzr() 15)sition
of the
veit, catluter
vlie,,
pLoced
ptrcntaiucnislv
froiis the ftnural
vein into) the r-,,al
vein. ( ld injectali
exits
tIn r(!htl vei,i (athettr
tt the site
lalkd
iIijtctott
s)rt
.
dfl(l ))d%S(S
tl
tlarnistor
as
blood
fIovs into
tlit inferior
veii cava (I().
( atl,ettr
I))rts
ot the
injectate
dII(l tliorinistor
sites allov
renal tjti
sanipling
for accurate
deternunatn)n
( )1 IA1
I txtraction
c vihcio,its.
Ii;ieer:
Alxh,niual
radiograph
sln)viIIg tl,trenal
eii (atl,rt(r in tIe correct
Is)sitn)II
for RBF (loterlninatit)Il
H, the left rtntl
iiu ola criticall
ill 1)Lt1(Ilt.

renal

CHEST

Downloaded From: http://journal.publications.chestnet.org/ on 03/22/2016

I 98

I 1 I JULY,

1990

171

greater

and

than

50

pressure

<60

pressure
mm)

Hg,

than

were

Hemodynamic

Arterial
artery

patient

Thermodilution

Serial

monitored

its

measurements

thermodilution

wedge

capillary

paper

was

wedge

venous

cardiac

Hg])

x &V(CO).
vein

output

made

index

from

and

systemic

to standard

Renal

x 80/RBF

(IJmin)(,,,,,

by

the

of

the
on

vascular

formulas:

CI

(11
[mm

sive.

If the

renol

was

added,

mm.

All

patients

was

patient

added

ifthe

>20

pg/kg

required
and

the

received

was

blood

culture

results

adjusted

accordingly.

maintain

a normal
including

phosphate,

sterile

Miami,

guidance.

was

oxygen

renal

were

determined

promptly

corrected.

port,

in the

PAH

and

Inulin

for

and
were

each

evaluations

were

mid-

For

each

of room

tern-

values

were

low
averaged.

Thermo-

injection.

Concurrent

with

obtained

each

of

set

RBFs.
and

Concurrent

Renal

RBFs,

Measurements
inulin

evaluations

intensive

to 72 h when

care
feasible

clearances,

were

and

obtained

unit

for shock

(Fig

3).

complete

within

and

systemic

18 h of admission

repeated

over

the

next

24

Analysis
statistics

ranges.

Initial

using

two-tailed

variables

and

are

paired

were

reported

follow-up

assessed

as means

values
t tests.

using

were

standard

compared

Correlations
linear

errors

among

between

regression

and

patients
continuous

analysis.

RESULTS

Catheter

Calibration

and

Thermodilution

catheter

strongly

(r = 0.997,

Computation

amounts

collected

(Appendix
shown

measurements

p<O.OOl)

when

volumetrically

correlated
with the

compared

in the

in vitro

1 , Fig 2). The catheter


measurements
to be accurate
over the range
of flows

to 2,500

system
were
from

150

mI/mm.

vein

vein

site

length.

in samples

ofa

was

in

the

was

No other

to accommodate

vessels
the

catheter

caval

samples

the

cava.

ofthe
vein

high

renal

and

standard methods
measurements
were made:
age = 100
x (arterial,PAH,
flows

were

mulin

clearance

(Appendix

in

that

the

The

renal

vein

of the

renal

use

PAH
renal

corrected

extraction

vein

are

for the

decreased

were

following

coefficient

Thermodilution
Renal
Flow Determinations

90

120

derived
percentEffective

extraction

172

Downloaded From: http://journal.publications.chestnet.org/ on 03/22/2016

of

Blood

PAH and Inulin Levels


obtained
(urine,
arterial,
renal vein)

catheter

determinations

vein(PAHI)/artenal,PARI

60

Inulin
Bolus
and Infusion

of

catheter.

The

fernoral

Clearances

using

(mins)

Systemic
Hemodynamic
Determinations

change

to confism

in the area
renal

(c)

the

vena

Collection
Period

PAH Bolus
and Infusion

blood

abdominal

and

into

used

the placement

to confirm

(a)

temperature

inferior

2nd

position-

vena

injected

detectable

thermistor
not

from

Time

passed

for renal
by

obtained

solution

was

curve,

drawn

1st Collection
Period

Period

fluoroscopic

Correct

confirmed

Equilibration

Co.

percutaneously

under

preferred

was

infiltrated
(Cordis

catheter

thermodilution

cold saline
the absence

Para-aminohippurate

plasma

the

locally

vein

vein

renal

to concurrently

dye

enough

renal

characteristic

not necessary.

large

was

was

fernoral

of its greater

saturation

When

fluoroscopic

renal

paramcreatinine,

introducer

renal

the

into

vein

area

the

The

because

in comparison
2).

femoral

into
and

the renal vein catheter


catheter
position
was

made

to

nitrogen,

glucose,

high

outputs

obtained

at the

inulin.

injections

The
five

and

Determination

were

as needed

Metabolic

urea

a 6-French

technique.

left

(b)

introducer

the

introduced

catheter

radiograph,

was

percent.

and

agents

given

abnormalities

and

introducer

The

ing ofthe

(Fig

was

blood

magnesium

lidocaine

measurements

ports

electrolytes,

any treatable

Seldinger
the

venous

antibiotic

support

an SaO,>90

procedures,

FL)
the

through
flow

the

Obtained,

and

serum

1 percent

using

were

hemodynamic

Hemodynamic

to the

hand-force

obtained.

obtained

for PAH

Placement

Using
with

were

calcium,

Catheter

curves

In Vitro

levarte-

to 2 to 3 pg/kg

antibiotic
coverage,
a cephalosporin,
and a semiPseudomonas
aeruglnosa.
When

Respiratory
pH

4 to 8 h and

every

were

were

period

maximal

and the remaining

broad-spectrum

usually including
an aminoglycoside,
synthetic
penicillin
active
against

ERPF/

hypoten-

of dopamine,

tapered

PAH)

Flow Determinations

collection

D5W

Statistical

remained

mlii

dopamine

RBF(,,,,,,.,J

as =(MAP-

PAH ..*bd)

patient

coefficient.

extraction

as:

determinations

perature

Descriptive

Dopamine

Blood

discarded

hemodynamic

All the patients


were treated
by the same
group
of critical
care
physicians
employing
the following
sequential
treatment
protocol
to maintain
a MAP>60
mm Hg. Initially,
patients
received
fluids
intravenously
to maintain
a pulmonary
capillary
wedge
pressure
of
Hg.

30-mm

thermodilution

Protocol

15 mm

CPAH/PAH

calculated

RBF
seven

complete

tracings

and SVR (dynesscm)=(MAF-CVP


vascular
resistance
was calculated

pressure)

Renal

ofeach

dilution

pressure,

Measurements

were

according

artery

radiographically.

(m),

renal

Treatment

and

Cardiac

calculated

were

min/m)=CO/BSA

in the pulmonary

obtained.

pressure

cath-

A pulmonary

confirmed

pressure
were

at end-expiration.

resistance

arterial

patients.

6 to 8 h) of central

technique

pulmonary

in all

was placed

position

(every

capillary

pulmonary

via an indwelling

artery

ERPF

was

Thermodilution
determination,

catheter

and

formula:
flow

cells/cub

to concomitant

antibiotics.

or femoral

flotation

balloon

of each

was

radial

the

blood

(1-hematocrit).

Evaluations

pressure

in the

eters,

using

Renal

in systolic

<500

ascribed

PAH

arterial

decrease

(neutrophils
that

baseline),

(mean

50 mm

neutropenia
cultures

broad-spectrum

from

hypotension

point

Systemic

graph

pressure

fever,

or greater

blood

with

in systolic

(b)

or

baseline),

negative

treatment

decrease

cultures,

mm

from
and

eter

mm

blood

positive

FIGURE
3. Protocol
for concurrent
measurement
of RBF and GFR
determination
by CPAH , inulin
clearance
and thermodilution
methods. lIme
in minutes
is depicted
on the horizontal
line; PAH and
inulin
boluses
were
administered
at time
0, followed
immediately
by continuous
infusions
ofboth,
After a 60-mm
equilibration
period,
two 30-mm
collection
periods
were
begun;
PAH and inulin
level
were obtained
from urine,
arterial,
and renal vein blood samples
at
60, 90 and 120 mm.
Systemic
hemodynarnic
and thermodilution
RBF measurements
were obtained
midway
through
each collection
period
at 75 and 110 mm.

Renal

Blood

Flow

Abnormalities

in Septic

and Critically

Ill (Brenneretsi)

12 determinations

in six patients;

[Fig 6]). Renal


septic
patients
range

blood
flow
at the time

of 112

to

1,767

mI/min

mm) by corrected
up evaluation,
after

CPAH.

patients

to a mean

of 737

4,E]).

Renal

15,600
did

not

5,822

systemic

hemodynamic
at the

Renal

blood

flow

There

dosage

179

p>O.2O).
directly
with
(CI,

also

was

no

did

SVR

not

any

or arterial
The

change

to the kidneys
(RBF/
(Fig 4,H [p<O.O5fl.
correlate

correlation

with

between

kidneys

in any of these

or changes

pressor

during

Glomerular

filtration

four

was

ofseven

reduced

septic

rate

patients.

(range,

18 to 126 mI/mm).
significantly
(0.36 mg/dL
the

first

24 h of shock

filtration

(r =

Initial
Serum

by
<60

GFR

inulin

mI/mm)

varied

in

in these

levels rose
p = 0.012)
within

patients.

of total
blood
flow
r = 0.92,
p = 0.003

Glomerular

filtration
rate
determinations.

did

not

change

going
[Fig

the feasibility
in critically

to
7]).

signfficantly

the
Gbon

a variety

confirm

accurate

including

vein

need

for renal

catheters
unit.
reducdue to

with

renal

Our results
are
PAH kinetics

catheterization

of RBF;

for these

PAH

strong

correlation

p<O.05)

across

patients
Renal

(112 to
hemodynamics

in

the

RBF among

found

decreases

in significant

lution-determined

for

extractions

was

found

RBF

and

wide

range

1,767

in PAH

errors

in the

thermodi-

methods

ofbbood

extrac-

estimation

between

CPAH

(r = 0.79,

flows

in these

mI/mm
blood
flow; [Fig 5]).
demonstrated
large
variability

patients

with

sepsis,

by previous

12,

similar

to results

No direct

correla-

tion was found


between
RBF and CI among
patients
at the time of initial presentation.
All patients
showed
an increase
in RBF when
comparing
initial
to followup evaluations
(p<0.05).
Thus,
the total RBF and the
of blood

flow

between

vascular
resistance
the

oftotal

going

to the

initial

and

index
did

study

findings

and

suggest
occurring

The overall
for the patients

documents

vein
care

interference

the

ring to a corresponding
It is unknown
whether
priate
renal vascular

and

variable
patients

flow817
ofaltered

result

vasodilation
0

study

shunting
ofbbood
with observations

to account

tion would
of RBF.

throughout

LU

This

CPAH

ranged
from 28 to 90 percent
in our patients
(mean,
55.7 5.6 percent;
normal
values
exceed
90 percent).

These

rr

that
The

indwelling
renal
in the intensive

determination

as systemic
vascular

RBF.

of causes

catheter
ill patients.

RBF by two techniques:


coefficient
determination)

of using
ill patients

significantly

vein

critically

PAH secretion
secondary
to tubular
dysfunction,
competition
for anionic
secretory
sites by drugs,
interference
of assay measurements
by various
medications,

fraction

LU

renal

and

Previous
investigators
have found
tions in renal PAH extraction
in septic

creatinine

increase,

in septic

catheter
can determine
bevels (with extraction

widely

did not correlate


directly
with
RBF
p = 0. 14). However,
GFR correlated
closely

with
the fraction
kidneys
(RBF/CO;
follow-up

GFR,

rate

0.505;

merular

determined

(initial

developed
RBF

Failure

recovery.
clearance

measures

and

dopammne

parameters

have

and possibly
in agreement

or levophed
dosage
and initial
RBF, follow-up
value,
percentage
of blood
flow going
to the

RBF

We

thermodilution-derived

[Fig

of follow-up

evaluation.

flow going
of follow-up

mI/

on followin septic

(p<O.O5

time

correlate

of initial

DISCussIoN

averaged
evaluation
and

dynes.s.cm,

not

parameter

time

in the fraction
ofblood
CO)
rose at the time
dosage.

mL/min

at the

3,365
did

percent
among
with a

690

resistance
on initial

significantly

(11,050
blood
flow

pressure)

(mean,

168

dynes.s.cm

evaluation
Renal

>90

Renal
blood
flow
24 to 72 h, increased

vascular

change

normal,

varied
considerably
of initial
evaluation

blood

increased
not change
did

not

that

the

in septic

increased

measurements,

(p<O.05).
Renal
significantly

correlate

with

profound
patients

SVR.

systemic
is not

occur-

degree
in the renal vasculature.
these findings
represent
approregulatory
functions.

adequacy
in our
flow

kidneys

final

going

of RBF is difficult
to assess
study.
The rise in the fraction
to the

kidneys

during

recovery

from
sepsis
suggests
that
the
vasodilation
in the
systemic
circulation
during
the initial
phase
of the
septic episode
was not matched
in the renal circulation.

10
RBF/CO

FIGURE
7. Correlation
to the kidneys
with
correlation
coefficient

20

these

total blood
flow
phase
of sepsis.

(%)

ofthe
initial fraction
oftotal
blood
GFR (by inulin
clearance)
in septic
of0.92
was obtained
(p=0.003).

As a result,

flow going
patients.
A

dilation
blood

occurred

patients

had

fraction

of their

going to the kidneys


during
the
During
recovery,
less systemic
resulting

in a higher

fraction

acute
vaso-

of renal

flow
CHEST

Downloaded From: http://journal.publications.chestnet.org/ on 03/22/2016

a lower

I 98 I I I JULY, 1990

175

1600

m2).

C
E

:Do
6Li

1200

following

recovery

(Fig

improved

clinically

when

an average

800

sure

Y=553+0.53X
R=0.79

600

mm
(from

P=0.036

w
400

dilI.c

1000

2000

5.

Correlation

with CPA,, methods


was

BLOOD

ofinitial

RBFs

in milliliters

FLOW

(mi/mm)

measured

coefficient

obtained

with
a slope
of 0.47
(p<0.01).
Although
RBFs overestimated
PAH-determined
blood
flows
and underestimated
blood
flow at high rates,
this could
for by the regression
equation.

thermodilution
at low rates
be corrected

decreased
(p = NS)

toward
(Fig 4,A).

between

thermodilution

and

Renal

flow

blood

1.04)
according
to the standard
protocol.
At the conclusion
of the
dosages
ranged
from
0 to 2 pq,/kg/

min (mean,
0.57 p.g/kg/min,
SEM,
0.36).
Initial
RBF
did not correlate
with the
mine

dose

change

in

did

not

r =

0.25)

(p = 0. 129;

RBF from
correlate
or the

r = 0.630).

onset

with
change

initial

dopamine
in dopamine

also

Hg) (p<0.05).
at follow-up)

and

Renal

Carhad

significantly
occurred

or pulmonary
the study
period.

Renal

12.5

significanfly

normal,
though
not
No signfficant
change

vascular

normal
to
blood
pres-

in

capillary

Function:

Blood

by

Flow

Methods

determined

by

the

degrees

at the

evaluation

studied

(mean,

ofinitial

56.3 percent;

thermodilution

the

corrected
C
PAH extracreduced
to variable

with

51). The

range,

in the

patients

28 to 90 percent;

100

also

(pO.66;
dosage
with

80

0
0

l-z

r=0.60).

<LU

Only
during
tically.
levophed

two patients
were
on levophed
at any time
the study,
making
it difficult
to evaluate
statisHowever,
the patient
on the highest
dose
of
during
the initial
measurement
(9 p.g/min)

the

study)
been

smallest

Renal

All patients

ments

change

at the time
discontinued.

Baseline

in RBF

of recovery

(of all patients


when

0-u-

60

-LU

had
<C-)

ch

had

baseline

within

serum

36 h prior

creatimne

measure-

to the onset

but one patient


had a serum
creatinine
than 1.5 mg/dl
(range,
0.7 to 3.4; mean,
0.89).

20

of sepsis.

level less
1.45; SEM,

0
The

Hemodynamic
systemic
with

40

Function

obtained

Systemic

in the

all pressors

All

tients

increased

mm
IJmin/m2

recovery
(p = 0.226;
r = 0.58).
Dopamine
concentrations
also did not correlate
with
the GFR
(p = 0.20;

had

Systolic

MAP

had
after

the

to follow-up
dose

patient

6.4 to 127.3

[Fig
were

time

one

at follow-up

correlated
strongly
clearance
(r = 0.79,
p<O.O5
tion coefficient
percentages

dopa-

Additionally,

of sepsis

but

toward

106.5

method

pg/kg/min;
SEM,
patient
therapeutic
study,
dopamine

All

from

5.0

Hemodynamics

Correlation

199

24 to 72 h). Systemic

to 86.06.5
(mean,

Hg),

reduced
during
the
with levels obtained

(p<0.01).

and

71.93.6
index

Renal

by thermodilution

A correlation

perminute.

p<O.OS)

mm
(565

6.4

SVR

evaluated

pulmonary
artery
pressures,
wedge
pressure
throughout

PARA-AMINOHIPPURATE
RENAL

Hg,

and

significantly

increase

(mean

4).

h (range,

increased
dynes.scm5

(106.5

Hg)

were
significantly
when
compared

of44

resistance

790 130

crO

0.94

pressure
mm

dynes#{149}s.cm5)
initial
evaluation

1000

FIGURE

blood

(71.93.6

1400

zE

of

Systolic

MAP

Results

hemodynamics

serial

namic
state
at the
The initial
CI was

measurements

I,

PAH
in the
revealed

six septic

pa-

EXTRACTION

COEFFICIENT

a hyperdy-

time
of the initial
measurements.
elevated
(mean,
5.5 0.43 L/min/

174

Downloaded From: http://journal.publications.chestnet.org/ on 03/22/2016

6. Renal PAH extraction


coefficients
for ten measurements
in five septic patients.
Mean extraction
coefficient
was 55.7 percent;
normal coefficients
are >90 percent.
FIGURE

Renal Blood Flow Abnormalities

In SeptIc and CrItically

III (Brenner

eta!)

12 determinations

in six patients;

[Fig 6]). Renal


septic
patients
range

blood
flow
at the time

of 112

to

1,767

mI/min

mm) by corrected
up evaluation,
after

CPAH.

patients

to a mean

of 737

4,E]).

Renal

15,600
did

not

5,822

systemic

hemodynamic
at the

Renal

blood

flow

There

dosage

179

p>O.2O).
directly
with
(CI,

also

was

no

did

SVR

not

any

or arterial
The

change

to the kidneys
(RBF/
(Fig 4,H [p<O.O5fl.
correlate

correlation

with

between

kidneys

in any of these

or changes

pressor

during

Glomerular

filtration

four

was

ofseven

reduced

septic

rate

patients.

(range,

18 to 126 mI/mm).
significantly
(0.36 mg/dL
the

first

24 h of shock

filtration

(r =

Initial
Serum

by
<60

GFR

inulin

mI/mm)

varied

in

in these

levels rose
p = 0.012)
within

patients.

of total
blood
flow
r = 0.92,
p = 0.003

Glomerular

filtration
rate
determinations.

did

not

change

going
[Fig

the feasibility
in critically

to
7]).

signfficantly

the
Gbon

a variety

confirm

accurate

including

vein

need

for renal

catheters
unit.
reducdue to

with

renal

Our results
are
PAH kinetics

catheterization

of RBF;

for these

PAH

strong

correlation

p<O.05)

across

patients
Renal

(112 to
hemodynamics

in

the

RBF among

found

decreases

in significant

lution-determined

for

extractions

was

found

RBF

and

wide

range

1,767

in PAH

errors

in the

thermodi-

methods

ofbbood

extrac-

estimation

between

CPAH

(r = 0.79,

flows

in these

mI/mm
blood
flow; [Fig 5]).
demonstrated
large
variability

patients

with

sepsis,

by previous

12,

similar

to results

No direct

correla-

tion was found


between
RBF and CI among
patients
at the time of initial presentation.
All patients
showed
an increase
in RBF when
comparing
initial
to followup evaluations
(p<0.05).
Thus,
the total RBF and the
of blood

flow

between

vascular
resistance
the

oftotal

going

to the

initial

and

index
did

study

findings

and

suggest
occurring

The overall
for the patients

documents

vein
care

interference

the

ring to a corresponding
It is unknown
whether
priate
renal vascular

and

variable
patients

flow817
ofaltered

result

vasodilation
0

study

shunting
ofbbood
with observations

to account

tion would
of RBF.

throughout

LU

This

CPAH

ranged
from 28 to 90 percent
in our patients
(mean,
55.7 5.6 percent;
normal
values
exceed
90 percent).

These

rr

that
The

indwelling
renal
in the intensive

determination

as systemic
vascular

RBF.

of causes

catheter
ill patients.

RBF by two techniques:


coefficient
determination)

of using
ill patients

significantly

vein

critically

PAH secretion
secondary
to tubular
dysfunction,
competition
for anionic
secretory
sites by drugs,
interference
of assay measurements
by various
medications,

fraction

LU

renal

and

Previous
investigators
have found
tions in renal PAH extraction
in septic

creatinine

increase,

in septic

catheter
can determine
bevels (with extraction

widely

did not correlate


directly
with
RBF
p = 0. 14). However,
GFR correlated
closely

with
the fraction
kidneys
(RBF/CO;
follow-up

GFR,

rate

0.505;

merular

determined

(initial

developed
RBF

Failure

recovery.
clearance

measures

and

dopammne

parameters

have

and possibly
in agreement

or levophed
dosage
and initial
RBF, follow-up
value,
percentage
of blood
flow going
to the

RBF

We

thermodilution-derived

[Fig

of follow-up

evaluation.

flow going
of follow-up

mI/

on followin septic

(p<O.O5

time

correlate

of initial

DISCussIoN

averaged
evaluation
and

dynes.s.cm,

not

parameter

time

in the fraction
ofblood
CO)
rose at the time
dosage.

mL/min

at the

3,365
did

percent
among
with a

690

resistance
on initial

significantly

(11,050
blood
flow

pressure)

(mean,

168

dynes.s.cm

evaluation
Renal

>90

Renal
blood
flow
24 to 72 h, increased

vascular

change

normal,

varied
considerably
of initial
evaluation

blood

increased
not change
did

not

that

the

in septic

increased

measurements,

(p<O.05).
Renal
significantly

correlate

with

profound
patients

SVR.

systemic
is not

occur-

degree
in the renal vasculature.
these findings
represent
approregulatory
functions.

adequacy
in our
flow

kidneys

final

going

of RBF is difficult
to assess
study.
The rise in the fraction
to the

kidneys

during

recovery

from
sepsis
suggests
that
the
vasodilation
in the
systemic
circulation
during
the initial
phase
of the
septic episode
was not matched
in the renal circulation.

10
RBF/CO

FIGURE
7. Correlation
to the kidneys
with
correlation
coefficient

20

these

total blood
flow
phase
of sepsis.

(%)

ofthe
initial fraction
oftotal
blood
GFR (by inulin
clearance)
in septic
of0.92
was obtained
(p=0.003).

As a result,

flow going
patients.
A

dilation
blood

occurred

patients

had

fraction

of their

going to the kidneys


during
the
During
recovery,
less systemic
resulting

in a higher

fraction

acute
vaso-

of renal

flow
CHEST

Downloaded From: http://journal.publications.chestnet.org/ on 03/22/2016

a lower

I 98 I I I JULY, 1990

175

This study
interventions

was not designed


on RBF or renal

to assess
function.

the effects
Additionally,

of

Previous

investigations

atinine

clearance

have

shown

measurements

that
are

standard

cre-

insensitive

meas-

with the limited


number
of patients
involved
in this
study,
it is not possible
to draw
conclusions
regarding
the role of pressors
in RBF during
sepsis.
All pressor

ures ofthe
GFR in mild renal dysfunction
and become
progressively
less accurate
with decreasing
GFR.2
In this study,
GFR
determined
by inulin
clearance

agent
adjustments
used
in
according
to systemic
blood
While
no correlation
between

correlated
closely
with the fraction
going
to the kidneys
(RBF/CO),

was

seen,

this

cannot

pressor.related
RBF techniques
which

be

effects

The correlation
thermodilution

could

as evidence

against

was strong
between
RBF
measurements

clearance
methods.
is similar
to regression

catheter

models.

Thermo-

and that there


is minimal
shunt
flow from
draining
into the renal
vein (eg, spennatic,
adrenal,
renal capsular
veins).
These
assumphave

been
These

modilution

RBF

methods

A disadvantage
is that
from
This
was

the
the

can

of the

thermistor
cold

bolus

information

thermodilution

must

injectate

be

completely

before

is accomplished
designed

provide

it

by using

the

that

injectate

to assure

exits

in

to 3 cm
injectate
must

thermistor
must
lay
vein,
a maximum
distance

can separate
solution
with

take

place

them
blood

within

average
rates
limits
for the

of RBF
accuracy

tion methods,
RBF in these

there was
patients.

The
study

Complete
flowing

this
approach
of bolus

use of standard
is not optimal

a strong

natively,

the

be

which

and

of the
a direct

progressive

RBFs

of greater

renal

than

mu

900

relationship
constriction,

between
(2) relative

caused

renal

renal
tissue
(3) induction

blood

to the

afferent
and
inadequacy

flow

insertion

abnormalities

of the

dysfunction
that

are

that

catheter.

in these

by mechanisms

metabolic
of renal
Alter-

patients

unrelated

may
to total

Previous
blood
flow

reports
of renal
vein
determination
reveal

complications

from

cannulation.9b0,
reports
ofrenal

procedures

involving

We have
catheters

vein

catheterization
a low incidence

apparent

studied.
and
the

when

Excursion

not found
remaining

a larger

ofthe

body motion
inferior
vena

renal

series
veins

of

renal

vein

any previous
in situ for up

to three days as in this study. Our patients


no complications,
although
complications
more

and

experienced
may become
of patients

during

caused
the catheter
cava in some patients.

is

respiration

to migrate
into
The catheter

correlation

emphasizes
the need
to serially
evaluate
the catheter
position
using abdominal
radiographs
and characteristic renal vein thermodilution
curves.
In conclusion,
we have found
that renal vein catheterization
can be performed
safely
in the intensive

bolus
CO
for RBF

the
was

a reflection
rather
than

RBF.

cath-

the

vasodiGFR

had to be replaced
over a guidewire
for some
follow-up
RBF determinations
in five patients.

in the critically
ill.
techniques
(including
and software
optimized

may further
improve
Inulin
clearance

Although

be
sepsis

developed

by transient

catheter.

completely
of only

then

flow due to increased


due
to sepsis,
or

insulated

the

non-renal
decreased

the theoretic
lower
injectate
thermodilu-

accuracy.
used
to

with

PAH

equipment
in this
ranges.
The
close

correlation
between
thermodilution
shows
promise
for instantaneous
serial
measurements
tions of these
tion methods,

of blood
demands

prior

mixing
of the
in the renal vein

distance.

in the
arteriolar

dysfunction

eter at a point
most proximal
in the renal
vein, then
passes
the thermistor
on the distal
tip of the catheter
on the way to the inferior
vena cava (Fig 3).221
The
pigtail
catheter
can generally
be inserted
only 2 to 3
cm into the renal
vein.
Since
both the injectate
port
and
the
detector
within
the renal

repeated

occurred

shape

leaves

failure

method
the

pigtail

ischemia.
patient

despite

profound
between

result
of renal
One
septic

alteration
efferent

on

in RBF that may be valuable


with rapidly
changing
physiology.

flow
RBF.

mm. Thus,
renal
dysfunction
in septic
patients
may
occur
in the absence
of detectable
absolute
decreases
in RBF.
Pathophysiobogically,
this may represent:
(1)

shown
to be valid
in most
padata suggest
that the use of ther-

rapid,
serial
changes
critically
ill patients

of more

correlation

RBF
might
of the underlying

severity

kidneys,
vessels
ovarian,

I#{176}--

a marker
The

fractional

RBF determination
by this method
assumes
renal vein is present
on the side of measurethat
equal
blood
flow
is occurring
to both

tions

be

lation.

dilution
a single
ment,

blood
total

for increased
renal demands.
Alternatively,
the
fraction
of blood
flow to the renal
circulation

may

(and slope)
previously

of total
but not

The close relationship


between
GFR and the fraction
of blood
flow
going
to the kidneys
suggests
that
relative
shunting
away
from
the renal
circulation
may be occurring
during
sepsis,
with inadequate
blood
supply
lower

instantaneous
and continuous

This correlation
equations
reported

RBF

injectate

by

be investigated.

CPAH

bolus

taken

effects.
Instantaneous
thermodilution
may represent
an excellent
means

such

with

this
study
were
made
pressure
parameters.
pressor
doses and RBF

RBF
and
thermodilution

CPA)1

Future
modificacontinuous
injecin RBF ranges)

care
were

176

Downloaded From: http://journal.publications.chestnet.org/ on 03/22/2016

GFR.

environment
complications

catheterization

required
due

determine

unit
no

to

extraction
Renal

on critically
ill patients.
There
in our patients.
Renal
vein
direct
renal
determination

and

for

accurate

variable
of PAH
Blood

Flow

of the
This

and

significantly

in septic
Abnormalities

patients.
in Septic

blood

sampling
of RBF by

decreased

In our
and Critically

are
CPAH

renal

septic
III (Brenner

and
et a!)

critically

ill patients,

modilution

RBF

the

percutaneously

catheter

proved

to be

placed

ther-

accurate

and

can remain
intravascularly
to allow serial instantaneous
measurements
during
a period
of several
days. This
study
demonstrates
the potential
utility
of RBF catheters

in defining

the

pathophysiology

tion in septic
patients.
be useful
in evaluating
tions

RBF

on

ofrenal

dysfunc-

Renal
vein catheters
the effects
ofvarious

and

renal

function

also may
interven-

in

critically

ill

patients.
ACKNOWLEDGMENTS:
We would
like to thank
Ms. Debbie
Tribett
and the 1OD-ICU
nursing
staff for their
help and support
with this project.
We would
also like to thank Mrs. Julie Jordan,
Mr.
Gary
Morrison
and the technical
staff of 1OD for their technical
assistance
and advice.

The
for the
the

computation
relationship

constant
between

thermodilution

is the conversion
the integrated
area

temperature

curve

and

factor
under

the

actual

flow
rate
of the
Manual:
A Guide

fluid
(Hewlett-Packard
Reference
to Hemodynamic
Monitoring
Using

the
Swan-Ganz
Warmed
fluid

Catheter,
pumped

was

Hewlett-Packard
through
the tubing

in Figure
1 and collected
volumetrically.
vitro) were determined
as follows:
the
catheter
against
pump

Corp,

New

diameter

tubing

was

Thermodilution
CO

Packard

Co).

Co).
shown

The CC
thermodilution

(in

was introduced
30 cm upstream
in the tubing
a flow of water
produced
by a variable
rotary
(Varistaltic
Pump,
A series
model
72-325-000,

Monostat

ternal

Using

indicator
minute)

York).

thermally
used

in

outputs
computer

Fourteen-millimeter

insulated

all

of

dilution
technique,#{176}
was determined
as:

volume

output

was

(model

for

studies

(1,

calculated

as:is

flow rate was


Thermodilution
and compared

then

each

1.5

injectate

and

3 ml)

by

IL).

All

injectates
in

range

the

from

room
was

used

130

this
was

with

range.
main-

dependent

(21.6#{176}to
on the

computer

for low

to 350

5 percent

temperature

Hewlett-Packard

VI of 1 ml was
ments

performed

at

VI used

using

varied
from
130 to
flow
measurements
with concurrent
volu-

39.7#{176}Cusing a heated
water
Scientific
Group,
Chicago,

were

water

24.2#{176}C).The

CC/(60)VI.

at intervals
within
perfusate
water
bath

36.1 and
Precision

25,

dextrose

flow

rate

mL/min.

flow

range

A VI

rate

system.

measure-

of 1.5

ml

was

used for flows from 350 to 1 ,500 mi/mm,


and VI of 3
ml was used for flow rates of 1,500
to 2,700 mI/mm.
The
bolus
injection
technique
using
maximal
hand
force was
modilution
flow rate.
each

employed
for all measurements.
Five therflow measurements
were obtained
at each
Thermodilution
curves
were
generated
for

thermodilution
to

output

ensure
(model

proper
R-302P:

using

a two-channel

positioning
Lexington

re-

and
injection
Instruments,

MA).

Taking
per

then

between

bath

Waltham,

liters

(TB-TI)

determined

our

metric
measurements
Temperature
of the

on a Hewlett-

(in

(in vitro)
1.foTB(T)dt

CC

were
in

Rotameter
2,700
mI/mm.
were
obtained

corder
technique

Stewart-Hamilton

presetting
the rotameter
volumetrically
to a known
rate and adjusting
the in vitro
thermodilution
CC to
obtain
the correct
flow rate. The CT for each injectate

C, Hewlett-Packard
the

CCs
used

rubber

measurements.

measured

(HP-78231

a modification

in-

Silicon

calibration

were

Thermal
volume

tamed

APPENDIX

utpu

into

and specific
the CC used

difference

in specific

heat

gravity
between
blood,
in vitro were calculated

account

the

water,
and
as:#{176}-3

D5W,

CC (in vivo)=(1.08)CT(60)VI
density

ii)

Thermodllutlon
Computer
wIth
Recorder

(D5W

1 08 = specific density
heat

In

Thermodllutl
CatheterVein
Renal

the
(

Variable

Rate FluId

Pump

this

case

adjusted
VI.

the

the

Consequently,

dilution
RBF and
ear.
Thus,
CCs

Fluid
Device

Appendix
FIGURE
1. This
figure
depicts
the system
used
for in
vitro
standardization
of the RBF catheter.
Computation
constants
relating
the area under
the thermodilution
flow curve
to the fluid
flow rate were
determined
and the accuracy
of the catheter
was
validated
by comparing
known
flow rates measured
volumetrically
to rates obtained
by the thermodilution
catheter.

constant

volumetric
and
the

by

thermo-

measurements
VIs have
been

is nonlinadjusted

and low
constants

flow rate ranges.


and their corresponding

flow ranges
for
CO computer

system

to be 0.037

determined

been

added

between

VIs over the applicable


on the
Hewlett-Packard
were

has

of flow

relation

this catheter
monitoring

for flow

VI of 1.0

ml,

0.063 for VI 1.5 ml, and 0.122 for VI of3.0


ml.
Following
insertion
of the catheter
into the renal
vein,
a standard
1.5-mb
bobus
VI was injected.
If
thermodilution

RBF

rate

was

found

CHEST

Downloaded From: http://journal.publications.chestnet.org/ on 03/22/2016

(blood)

component
the

accordingly
at high
The computation
Volumetric
Collecting

heat

computation

to subtract

(D5W
(blood) or x water)

specific

or water)

I 98

to be above
I 1 I JULY, 1990

1,500
177

mI/min,

the

priate

CC

was

VI

increased
Similarly,

selected.

mi/min

with

creased

to 1.0

the

to 3 ml and
for flow rates

sample,

initial

ml with

the approbelow
350

injectates

selection

ofthe

were

ratories
Pathology
The inulin
assay

de-

bowed

corresponding

by

assay

indoleacetic

variance
in 19 separate
injections)
in the eight
patients

measurements
was 0.014.

Average
total

(95

PAH

Clearance

An

continuous

infusion

fully

drained

of

PAH

calculated

was

followed

to obtain

a serum

After a 1-h equilibration


were obtained
Bladders

period,
were

by

an

indwelling

Foley

solution
and air irrigations
of the bladder
performed
ifurine
output
was less than 60 mI/h
collection

period.

samples
were
each collection
each
PAH

sample

obtained
period.
(Fig

clearance
X

UPAH

were

and

= U

corrected

tation
veloped

were
during

of
in

VPAH/(ArtPAH)

inulin

clearances

were

milliliter,
and V1 is measured
Para-aminohippurate
and
formed
Nuys,

of

from

was

absorbance

in

iso-amyl

the

with

obtained

as

V1,,/Art1,,.
in milligrams

of

the

methoxazole

concentration,

serum

and
before

Mpert

JS,

Little

Brown

3 Sladen

FN.

Dalen

Laboratories
University

(Van
Labo-

Ayres

MD:

JE.

4 Werb
nosis

Acute
SM.

renal

care

failure

Major

issues

AL.

renal

N.

septic

in critically
care

Aetiology,

failure

j5.

JD,

Schrier

BL,

RW

Stein

Little

JH.

In:

care

Baltimore,

2
(L/min)

of thermodilution
catheflow rates.
A correlation
p<O.OOl.

178

Downloaded From: http://journal.publications.chestnet.org/ on 03/22/2016

The

New

treatment

A,
outflow

Renal

prog-

Resuscitation

1971;
HL.

renal

circulation.

621-33,

Lucas

CE,

Donath

HJ.

V. The

in health

function

Press,

University

the

Priebe

in anesthesiology.

measurement

of the

renal

method.

therrnodilution

local

and

1951

venography.

Brown

and

In: Abrams

HL.

Co, 1983;

1327-63

kidney.

Philadelphia:

FC.

The

FE,

Werner

M,

sepsis.

Arch

Angiography.
WB

Saunders,

308-09
Rector

with acute
A.

glomerular
single

In:

renal

22:35-63

and

structure

by

acute

8:17-32

B, Rector

1981;

1984;

of

30:193-200
in

kidney

man

Renal

Little,

Brenner

1982;

hemodynamics

The

Oxford

in

the importance

198(Ys:

42:603-14

J, Slechta

Bred

homeostasis
13

Parrillo

and

unit.

Nephron

1980;

kidney:

York:

venous

12

medicine.

care

in the

and Co,

Brown

HW.

Boston:

MA:

results

ill patients:

diagnosis,

renal
failure
and ofendotoxaemia.

9 Hornych

11

Boston

environment.

in an intensive

Ann Rev Physiol

10 Abrams

with

PAH

1984:215-19

Acute

shock

Nephron

of0.997

absorb-

to the

7:95-100

5 Wardle

disease.

Flow

residual

medicine.

in Critical

and Wifldns,

R, Linton

Boston:

comparison
volumetric
a slope of 1.02,

iso-

sulfa-

1985:481-907

in an intensive

ofacute

1979;

Intensive

and Co.

Williams

8 Smith

Volumetric

after

the

REFERENCES

JE,

In vitro
against

samples

to

the

deof

difference

and

is proportional

Internationalanesthesiologycinics-the

2.
flows

urine
The

and

extraction

precipi-

1 Gardner
P, Arnow
PM.
Hospital-acquired
infections.
In: Harrison T, et al, eds. Harrison
principles
ofinternal medicine. New
York: McGraw-Hill
Book Co mc, 1987:470
2 Schuster
DP, Lefrak
55. Septic
shock.
In: Bippe
JM, Irwin ES,

6 Conger
failure.
7 Margolis

FIGURE

for

recently
removal

is proportional

extraction

following

acetate

using
involved

samples

amylacetate

per

Appendix
ter.determined
coefficient

developed

iso-amylacetate.

per milliliter
milliliters
per

in milliliters
per minute.
inulin
assays
were
per-

CA).
the stan-

with

interferes

a method

following

of management

by the Smith-Kline
French
CA) and by the Georgetown

and

Nuys,

concentration.

of 50 mg/kg
was
calculated
to attain
x

Van

the
sulfamethoxazole
methods.
This
assay

by precipitation

ance

Clearance

Standard

azo dye that is


Special
Chem-

Para-aminohippurate

method,

sulfamethoxazole

urine

VPAI/(ArtPAff-VenPAH)
in milligrams
is measured
in

measure
of GFR.
Bolus
injection
followed
by constant
inulin infusion
serum
levels of 10 to 20 mg/dl.
Inulin
Clearance
= U1,
The U1,, and Art1,, were
measured

to form the
(Smith
Kline

Laboratories,

sulfamethoxazole

and

minute.

Inulin

Bratforma-

salt

two
care-

and end
measured

measured

which

PAH,

arterial

at the beginning
PAH bevels were

(uncorrected)
PAH

except

vein,

the

diazonium

sulfamethoxazole

assay

PAH

colorimetric

utilized

assaying
PAH
levels
in patients
receiving
sulfamethoxazole/trimethoprim
Para-aminohippurate
levels
were
determined
in two patients
on trimethoprim-

2).

clearance

All values

ReIiaI

level

catheter

saline

the

by

dard

for

assay

involving

Kline

Preuss,
M.D.).
hydrolysis
fol-

reaction

PAH

Manual:

Smith

Because

bolus

of 1 to 2 mg/dl.
30-min
collections

reaction

Procedure

Inulin,

Method

mg/kg

The

tion followed
by coupling
assayed
colorimetrically
istry

APPENDIX

acid

quantification.

ton-Marshal

CC.

Department
(H.G.
utilized
acidification

The

simultaneous

filtration

rate

injection

and

clearance

Rosenberg
Surg

1K. Altered
1973;

determination
effective

technique.

renal

Acts

renal

106:444-49
in

children

plasma

flow

Paediat

Scand

of
by the
1971;

60:512-20

Renal

Blood

Flow

AbnormalIties

in Septic

and Critically

III (Brenner

at a!)

14

Aukland
and

15

K. Methods

for measuring

renal

Ann

Physiol

distribution.

regional

Rev

blood

flow:

1980;

total

flow

42:543-55

J, Ingelfinger JR. Robson AM. Measurement of renal function


without urine collection:
a critical
evaluation
of the constant-infusion
technic
for determination
inulin and para-aminohippurate.
N Engl J Med 1972; 287:1109Cole

BR,

priate
24

Giangiacomo

of

25

JA,

Gagnon

17

Sykes

BJ,

18

Rosenberg

19

Duarte

J, Schenk

Obstet

135:877-82

1K,

Gupta

CG,

and
20

Liedtke

F, Guo-Quing

L.

Cardiovasc

22
23

1982;

F, Tarazi

ofpigtail

26

into

blood

the

27

flow.

Pitts

FF.
Book

Lucas

CE,

Khan

AA.

filtration

rate

tests.

insuffi-

28

193:175:83

38:495-99
WH,

RC.

A critical

for measuring
New

J,

of the
Publishers
Lucas

EE,

Biggs

in normal

McIntyre

KM.

Lewis

support.

American

Kim

Onesti

EK,

I.

disease:

112:471-76
Lab

Invest

function

in the

and excretion

J Cliii

Textbook

of renal

Clin

AW, et al. Renal


hemodynamics

Invest

1959;

of advanced

Association,

G, Ramirez

1977;

Scand

subjects.

JA.

Heart

in renal

and

Boston:

Berlyne

of

389-94

life

cardiac

1987:XIII-5

0, Breast

Swartz

AN,

a reappraisal.

Br

C. Creatinine

Med

1969;

4:11-

GM,

renal

plasma

Little

Brown

improvement

29

Sato

renal

blood

flow

approach
basic

to local

surgery.

in man.

30 Fronek

Cardiovasc

kidney
mc,
Gerrick

and

body

fluids.

Res

Chicago:

H,

Eguchi

dobutamine

and

renal

Japan

Circ

of inappro-

A, Ganz

S. Comparative

and

dopamine

V. Measurement

cardiac

output

Lancet

study

of

on systemic
following

of flow

by local

in single

1964;

effects

hemodyopen

blood

heart
vessels

Cire Bes 1960;

thermodilution.

31

Ganz

32

Preuss

W, Swan
Am

JH.

Cardiol

HG,

Razavi

Chem

1988;

Measurement

of blood

1972;

29:241-46

MH,

Slemmer

in

the

presence

D,

Zein

of

flow
M.

by thermodiluColorimetry

sulfamethoxazole.

of
Clin

34:422-23

CHEST

Downloaded From: http://journal.publications.chestnet.org/ on 03/22/2016

M. Endogenous
rate.

blood flow in patients


J 1982; 46:1059-72

p-aminohippurate

1974:140-57
SJ. Mechanism

H, Hoerni

8:175-182

thermodilution:

difficulties.

S, Varley

and glomerular.filtration

Y, Matsuzawa

of adrenaline,

local

of the

Nilwarangkur

clearance

11:874-79

for

tion.

Medical

DS,

water

Surg

S. Determination

method.

of man:

solute and

including

to avoid

Physiology

Baldwin
kidneys

creatinme

and methods

protocols

function

Renal

1971;

16:359-54

catheters

A, Zito

1978;

Arch

Simonson

by thermodilution

clearance

11:576-80

Year
Cortez

study
renal

flow

namics

method
Bes

Magrini
1977;

experimental

renal
22:29-40

1980:49-65

Magrini

use

An

1978;

blood
Hulet

patients.
EK,

14

glomenilar
Renal

Pyrogenic

of measuring

Laboratory

CG.

thermodilution
21

RB.

of

In: Duarte
Co,

SL,

W.
Nephron

and sepsis. Arch Surg

trauma

the measurement
flow.

WG.

methods

after

Flamenbaum

ofprostaglandins.

clearance

Gynec

ciency

PW,

role

Hoie

of

validity
Surg

Ramwell

the

hyperemia:

in septic

T, Brodwall

separate

14

16

polyuria

Leivestad

I 98 I 1 I JULY, 1990

179

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