The authors would like to thank Prof(s). Piccoli and Pastori of the Department of Medical and Surgical Sciences, University of Padova, Italy, for providing the BIVA software. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The following protocol was approved (REF. 3057) and follows the guidelines of the human research ethics committee of Instituto Nacional de Ciencias M&#233;dicas y Nutrici&#243;n SZ. Furthermore, prior consent was obtained from the patients for this study.
NOTE: This procedure is to be used for measuring bioelectrical impedance analysis using tetrapolar multi-frequency equipment (see Table of Materials) and will provide accurate resistance and reactance values at a single frequ...

<ol>
	<li>da Silva, A. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Association+of+hyperhydration+evaluated+by+bioelectrical+impedance+analysis+and+mortality+in+patients+with+different+medical+conditions:+Systematic+review+and+meta-analyses.+Clinical+Nutrition+ASPEN+Association+of+hyperhydration+evaluated+by+bioelectrical.">Association of hyperhydration evaluated by bioelectrical impedance analysis and mortality in patients with different medical conditions: Systematic review and meta-analyses. Clinical Nutrition ASPEN Association of hyperhydration evaluated by bioelectrical.</a> Clinical Nutrition ESPEN. 28, 12-20 (2018).</li><li>Kammar-Garc&#237;a, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+Bioelectrical+Impedance+Analysis+parameters+for+the+detection+of+fluid+overload+in+the+prediction+of+mortality+in+patients+admitted+at+the+emergency+department.">Comparison of Bioelectrical Impedance Analysis parameters for the detection of fluid overload in the prediction of mortality in patients admitted at the emergency department.</a> Journal of Parenteral and Enteral Nutrition. 45 (2), 414-422 (2021).</li><li>Kammar-Garc&#237;a, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=SOFA+score+plus+impedance+ratio+predicts+mortality+in+critically+ill+patients+admitted+to+the+emergency+department:+Retrospective+observational+study.">SOFA score plus impedance ratio predicts mortality in critically ill patients admitted to the emergency department: Retrospective observational study.</a> Healthcare (Basel). 10 (5), 810 (2022).</li><li>Frank Peacock, W., Soto, K. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+technique+of+fluid+status+assessment).">Current technique of fluid status assessment).</a> Congestive Heart Failure. 12, 45-51 (2010).</li><li>Lukaski, H. C., Vega-Diaz, N., Talluri, A., Nescolarde, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Classification+of+hydration+in+clinical+conditions:+Indirect+and+direct+approaches+using+bioimpedance.">Classification of hydration in clinical conditions: Indirect and direct approaches using bioimpedance.</a> Nutrients. 11 (4), 809 (2019).</li><li>Bernal-Ceballos, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bioimpedance+vector+analysis+in+stable+chronic+heart+failure+patients:+Level+of+agreement+single+and+multiple+frequency+devices.">Bioimpedance vector analysis in stable chronic heart failure patients: Level of agreement single and multiple frequency devices.</a> Clinical Nutrition ESPEN. 43, 206-211 (2021).</li><li>Uszko-Lencer, N. H., Bothmer, F., van Pol, P. E., Schols, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Measuring+body+composition+in+chronic+heart+failure:+a+comparison+of+methods.">Measuring body composition in chronic heart failure: a comparison of methods.</a> European Journal of Heart Failure. 8 (2), 208-214 (2006).</li><li>Lukaski, H. C., Kyle, U. G., Kondrup, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+of+adult+malnutrition+and+prognosis+with+bioelectrical+impedance+analysis:+phase+angle+and+impedance+ratio.">Assessment of adult malnutrition and prognosis with bioelectrical impedance analysis: phase angle and impedance ratio.</a> Current Opinion in Clinical Nutrition and Metabolic. 20 (5), 330-339 (2017).</li><li>Piccoli, A., Rossi, B., Pillon, L., Bucciante, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+method+for+monitoring+body+fluid+variation+by+bioimpedance+analysis:+the+RXc+graph.">A new method for monitoring body fluid variation by bioimpedance analysis: the RXc graph.</a> Kidney International. 46 (2), 534-539 (1994).</li><li>Lukaski, H. C., Piccoli, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bioelectrical+Impedance+Vector+Analysis+for+Assessment+of+Hydration+in+Physiological+States+and+Clinical+Conditions.">Bioelectrical Impedance Vector Analysis for Assessment of Hydration in Physiological States and Clinical Conditions.</a> Handbook of Anthropometry. , 287-305 (2012).</li><li>Piccoli, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bivariate+normal+values+of+the+bioelectrical+impedance+vector+in+adult+and+elderly+populations.">Bivariate normal values of the bioelectrical impedance vector in adult and elderly populations.</a> The American Journal of Clinical Nutrition. 61 (2), 269-270 (1995).</li><li>Roubenoff, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Application+of+bioelectrical+impedance+analysis+to+elderly+populations.">Application of bioelectrical impedance analysis to elderly populations.</a> The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 52 (3), 129-136 (1997).</li><li>Espinosa-Cuevas, M. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bio+impedance+vector+an&#225;lisis+for+body+composition+in+Mexican+population.">Bio impedance vector an&#225;lisis for body composition in Mexican population.</a> Revista de Investigaci&#243;n Cl&#237;nica. 59 (1), 15-24 (2007).</li><li>Demirci, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impedance+ratio:+a+novel+marker+and+a+power+predictor+of+mortality+in+hemodialysis+patients.">Impedance ratio: a novel marker and a power predictor of mortality in hemodialysis patients.</a> International Urology and Nephrology. 48 (7), 1155-1162 (2016).</li><li>Plank, L. D., Li, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bioimpedance+illness+marker+compared+to+phase+angle+as+a+predictor+of+malnutrition+in+hospitalized+patients.">Bioimpedance illness marker compared to phase angle as a predictor of malnutrition in hospitalized patients.</a> Clinical Nutrition. 32, 85 (2013).</li><li>Castillo-Martinez, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bioelectrical+impedance+and+strength+measurements+in+patients+with+heart+failure:+comparison+with+functional+class.">Bioelectrical impedance and strength measurements in patients with heart failure: comparison with functional class.</a> Nutrition. 23 (5), 412-418 (2007).</li><li>Earthman, C. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Body+composition+tools+for+assessment+of+adult+malnutrition+at+the+bedside:+A+tutorial+on+research+considerations+and+clinical+applications.">Body composition tools for assessment of adult malnutrition at the bedside: A tutorial on research considerations and clinical applications.</a> Journal of Parenteral and Enteral Nutrition. 39 (7), 787-822 (2015).</li><li>Piccoli, A., Pastori, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=BIVA+software.">BIVA software.</a> Department of Medical and Surgical Sciences. , (2002).</li><li>Basso, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fluid+management+in+the+intensive+care+unit:+bioelectrical+impedance+vector+analysis+as+a+tool+to+assess+hydration+status+and+optimal+fluid.">Fluid management in the intensive care unit: bioelectrical impedance vector analysis as a tool to assess hydration status and optimal fluid.</a> Blood Purification. 36 (3-4), 192-199 (2013).</li><li>Piccoli, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bioelectrical+impedance+measurement+for+fluid+status+assessment.">Bioelectrical impedance measurement for fluid status assessment.</a> Contributions to Nephrology. 164, 143-152 (2010).</li><li>National Institutes of Health Technology. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bioelectrical+impedance+analysis+in+body+composition+measurement:+National+Institutes+of+Health+Technology+Assessment+Conference+Statement.">Bioelectrical impedance analysis in body composition measurement: National Institutes of Health Technology Assessment Conference Statement.</a> The American Journal of Clinical Nutrition. 64, 524-532 (1996).</li><li>Silva, A. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lack+of+agreement+of+in+vivo+raw+bioimpedance+measurements+obtained+from+two+single+and+multifrequency+bioelectrical+impedance+devices.">Lack of agreement of in vivo raw bioimpedance measurements obtained from two single and multifrequency bioelectrical impedance devices.</a> European Journal of Clinical Nutrition. 73 (7), 1077-1083 (2019).</li><li>Mulasi, U., Kuchnia, A. J., Cole, A. J., Earthman, C. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bioimpedance+at+the+bedside:+current+applications,+limitations,+and+opportunities.">Bioimpedance at the bedside: current applications, limitations, and opportunities.</a> Nutrition in Clinical Practice. 30 (2), 180-193 (2015).</li><li>Chabin, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bioimpedance+analysis+is+safe+in+patients+with+implanted+cardiac+electronic+devices.">Bioimpedance analysis is safe in patients with implanted cardiac electronic devices.</a> Clinical Nutrition. 38 (2), 806-811 (2019).</li><li>Gonz&#225;lez-Correa, C. H., Caicedo-Eraso, J. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bioelectrical+impedance+analysis+(BIA):+a+proposal+for+standardization+of+the+classical+method+in+adults.">Bioelectrical impedance analysis (BIA): a proposal for standardization of the classical method in adults.</a> Journal of Physics: Conference Series. 47, 407 (2012).</li><li>Di Somma, S., Gori, C. S., Grandi, T., Risicato, M. G., Salvatori, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fluid+assessment+and+management+in+the+emergency+department.">Fluid assessment and management in the emergency department.</a> Contributions to Nephrology. 164, 227-236 (2010).</li><li>Kammar-Garc&#237;a, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mortality+in+adult+patients+with+fluid+overload+evaluated+by+BIVA+upon+admission+to+the+emergency+department.">Mortality in adult patients with fluid overload evaluated by BIVA upon admission to the emergency department.</a> Postgraduate Medical Journal. 94 (1113), 386-391 (2018).</li></ol>

It is important to mention that different bioelectrical impedance analysis (BIA) approaches have been proposed in the published literature, including the use of multiple frequencies at 1-500 kHz (MF-BIA), phase-sensitive single frequency (SF-BIA) at 50 kHz, and spectroscopic BIA at 5 kHz to 2 MHz. Studies have provided inconsistent results, concerning the agreement regarding single- and multiple-frequency BIA equipment6, including source current, frequency, total impedance range over which the cur...

Fluid overload (FO), defined as an excess of total body fluid or a relative excess in one or more fluid compartments1, is frequently observed in critically ill patients and is associated with higher morbidity and mortality1,2,3. The range of alterations in hydration status is wide; can indicate renal, cardiac, or hepatic failure; and/or maybe the result of excessive oral intake or iatrogenic error4. Routine assessment of hydration status is challenging in emergency departments, as the gold standard of radioisotopic volume measurement requires specialized techniques, is costly and time-consuming, and may fail to identify early disturbances in hydration status. Hence, other less-accurate methods are generally used, including clinical examination and accumulated fluid balance (volume in mL in 24 h)5. Accurate and sensitive determination of fluid volume status is necessary to help clinicians in controlling body fluids, managing intravenous fluid administration, and maintaining hemodynamic stability, thus allowing patients to receive early treatment3,5,6. Errors in the volume assessment can lead to a lack of necessary treatment or to implementation of unnecessary therapy, such as excess fluid administration, both of which are related to increased hospitalization costs, complications, and mortality4.
Interest has recently increased in bioelectrical impedance analysis (BIA), which has been considered an alternative method for the classification of an individual&#39;s hydration status. BIA is a safe, non-invasive, portable, quick, bed-side, and easy-to-use method, designed for the estimation of body compartment composition. The analysis measures the opposition generated by soft tissues to the flow of an injected alternating electric current into the body (800 &#181;A), through four surface electrodes placed on the hands and feet. Total body water estimated by BIA has been shown to have a high correlation with that obtained by deuterium dilution (r = 0.93, p = 0.01)7.
Phase-sensitive BIA devices evaluate the direct measurement of phase angle and impedance (Z50), obtaining the resistance (R) and reactance (Xc) in single-frequency mode (50 kHz) or multi-frequency mode (5 kHz to 200 kHz)8. Dividing the R and Xc values by the subject&#39;s height (in m) squared-to control for inter-individual differences in conductor length-and plotting them in an R-Xc graph is the method used in bioelectrical impedance vector analysis (BIVA) to estimate the fluid status. BIVA is an alternative impedance approach, developed by Piccoli et al.9, which uses the spatial relationship between R (i.e., the opposition to the flow of an alternating current through intra- and extra-cellular ionic solutions) and Xc to assess soft tissue hydration, independent of the multiple-regression prediction equations generated in limited and specific samples10. Therefore, the classification of fluid status is more precise and accurate than the quantification of total body water. The R and Xc values of a subject produce a vector whose position can be evaluated relative to tolerance intervals in the R-Xc graph, which can be interpreted as indicating normal or abnormal hydration, based on the distance from the mean vector derived from a healthy reference population11,12,13.
In a previous study, we compared different bioelectrical impedance analysis parameters for the detection of fluid overload and prediction of mortality in patients admitted to an emergency department (ED) and demonstrated that BIVA (relative risk = 6.4; 95% confidence interval from 1.5 to 27.9; p = 0.01) and impedance ratio (relative risk = 2.7; 95% confidence interval from 1.1 to 7.1; p = 0.04) improved the estimation of the probability of 30-day mortality3.
Fluid overload can also be estimated using the impedance ratio (imp-R), which is the ratio between impedance measured at 200 kHz and impedance measured at 5 kHz obtained by the multi-frequency bioelectrical impedance equipment. Imp-R considers conduction in total body water (Z200) and in extracellular water fluid spaces (Z5). The penetration of a current into cells is frequency-dependent and, the 200/5 kHz ratio describes the ratio of greater to lesser current entry into cells3,8. If the difference between these two values decreases over time, it may indicate that the cells are becoming less healthy14.
Imp-R values &#8804;0.78 in males and &#8804;0.82 in females have been observed in healthy individuals15. Values nearer to 1.0 indicate that the two impedances are closer to each other, and the body cell is less healthy. In the case of critical illness, the resistance of the cell membrane at 5 kHz is reduced, and the difference between the impedance values at 5 and 200 kHz is markedly lower, indicating cellular worsening3. Values &#62; 1.0 suggest device error16,17. Thus, the objective of the present study is to demonstrate how to evaluate the presence of fluid overload through bioelectrical impedance vectorial analysis, as well as by using the impedance ratio, measured with tetrapolar multi-frequency equipment in patients admitted to the emergency department.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Alcohol 70% swabs</td>
			<td>NA</td>
			<td>NA</td>
			<td>Any brand can be used</td>
		</tr>
		<tr>
			<td>BIVA software 2002</td>
			<td>NA</td>
			<td>NA</td>
			<td>Is a sofware created for academic use, can be download in http://www.renalgate.it/formule_calcolatori/bioimpedenza.htm in &#34;LE FORMULE DEL Prof. Piccoli&#34; section</td>
		</tr>
		<tr>
			<td>Chlorhexidine Wipes</td>
			<td>NA</td>
			<td>NA</td>
			<td>Any brand can be used</td>
		</tr>
		<tr>
			<td>Examination table</td>
			<td>NA</td>
			<td>NA</td>
			<td>Any brand can be used</td>
		</tr>
		<tr>
			<td>Leadwires square socket</td>
			<td>BodyStat</td>
			<td>SQ-WIRES</td>
			<td></td>
		</tr>
		<tr>
			<td>Long Bodystat 0525 electrodes</td>
			<td>BodyStat</td>
			<td>BS-EL4000</td>
			<td></td>
		</tr>
		<tr>
			<td>Quadscan 4000 equipment</td>
			<td>BodyStat</td>
			<td>BS-4000</td>
			<td>Impedance measuring range: 20 - 1300 &#937; ohms 
			Test Current: 620 &#956;A 
			Frequency: 5, 50, 100, 200 kHz 
			Accuracy: Impedance 5 kHz: +/- 2 &#937; 
			Impedance 50 kHz: +/- 2 &#937; 
			Impedance 100 kHz: +/- 3 &#937; 
			Impedance 200 kHz: +/- 3 &#937; 
			Resistance 50 kHz: +/- 2 &#937; 
			Reactance 50 kHz: +/- 1 &#937; 
			Phase Angle 50 kHz: +/- 0.2&#176; 
			Calibration: A resistor is supplied for independent verification from time to time. The impedance value should read between 496 and 503 &#937;.</td>
		</tr>
	</tbody>
</table>

evaluation of fluid overload by bioelectrical impedance vectorial analysis

Early detection and management of fluid overload are critically important in acute illness, as the impact of therapeutic intervention can result in decreased or increased mortality rates. Accurate fluid status assessment entails appropriate therapy. Unfortunately, as the gold standard method of radioisotopic fluid measurement is costly, time-consuming, and lacks sensitivity in the acute care clinical setting, other less-accurate methods are typically used, such as clinical examination or 24 h output. Bioelectrical impedance vectorial analysis (BIVA) is an alternative impedance-based approach, where the raw parameter resistance and reactance of a subject are plotted to produce a vector, the position of which can be evaluated relative to tolerance intervals in an R-Xc graph. The fluid status is then interpreted as normal or abnormal, based on the distance from the mean vector derived from a healthy reference population. The objective of the present study is to demonstrate how to evaluate the presence of fluid overload through bioelectrical impedance vectorial analysis and the impedance ratio measured with tetrapolar multi-frequency equipment in patients admitted to the emergency department.

As an example of the method presented above, we present the results for two women admitted to the emergency department. Bioelectrical impedance analysis was assessed at admission using a phase-sensitive multi-frequency device (see Table of Materials), and the obtained resistance (R) and reactance (Xc) values were used to calculate the BIVA graph. The results show that patients with overhydration had worse prognoses and clinical characteristics such as SOFA and Charlson index scores, which are related to ...

Watch this Scientific Journal Video about Evaluation of Fluid Overload by Bioelectrical Impedance Vectorial Analysis at JoVE.com

Evaluation of Fluid Overload by Bioelectrical Impedance Vectorial Analysis

In this study, we demonstrate how to evaluate the presence of fluid overload through bioelectrical impedance vectorial analysis (BIVA) and the impedance ratio measured using tetrapolar multi-frequency equipment in patients admitted to the emergency department. BIVA and impedance ratio are reliable and useful tools to predict poor outcomes.

Early detection and management of fluid overload are critically important in acute illness, as the impact of therapeutic intervention can result in ...

evaluation-fluid-overload-bioelectrical-impedance-vectorial

Research

Education

JoVE Core

JoVE Journal

Anatomy and Physiology

Medicine

Unit 1

Fluid, Electrolyte, and Acid-Base Balance

SCIENTISTS IN ACTION

2.3K vistas.  Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. La detección temprana y precisa de la sobrecarga de líquidos es de importancia crítica en la enfermedad aguda, ya que el impacto de la intervención terapéutica puede resultar en una disminución o aumento de las tasas de mortalidad. El análisis vectorial de impedancia bioeléctrica es un enfoque de impedancia alternativa y un método utilizado para estimar el estado del fluido, independientemente de las ecuaciones de predicción de regresión múltiple generadas en muestras limitadas y ...