Can a renal nurse assess fluid status using ultrasound on the inferior vena cava? A cross-sectional interrater study: Ultrasound on the inferior vena cava

Introduction: Ultrasound of the inferior vena cava (IVC-US) has been used to estimate intravascular volume status and fluid removal during a hemodialysis session. Usually, renal nurses rely on other, imprecise methods to determine ultrafiltration. To date, no study has examined whether renal nurses can reliably perform ultrasound for volume assessment and for potential prevention of intradialytic hypotension. This pilot study aimed to determine if a renal nurse could master the skill of performing and correctly interpreting Point of Care Ultrasound on patients receiving hemodialysis. Methods: After receiving theoretical training and performing 100 training scans, a renal nurse performed 60 ultrasound scans on 10 patients. These were categorized by the nurse into hypovolemic, euvolemic, or hypervolemic through measurement of the maximal diameter and degree of collapse of the IVC. Scans were subsequently assessed for adequacy and quality by two sonologists, who were blinded to each other\u27s and the nurse\u27s results. Findings: The interrater reliability of 60 scans was good, with intraclass correlation 0.79 (95% confidence interval (CI) =0.63–0.87) and with a good interrater agreement for the following estimation of intravascular volume (Cohen\u27s weighted Kappa κw = 0.62), when comparing the nurse to an expert sonographer. Discussion: A renal nurse can reliably perform ultrasound of the IVC in hemodialysis patients, obtaining high quality scans for volume assessment of hemodialysis patients. This novel approach could be more routinely applied by other renal nurses to obtain objective measures of patient volume status in the dialysis setting

Derivation of a clinical decision-making aid to improve the insertion of clinically indicated peripheral intravenous catheters and promote vessel health preservation. An observational study

Background It is well established that the idle peripheral intravenous catheter (PIVC) provides no therapeutic value and is a clinical, economic and above all, patient concern. This study aimed to develop a decision aid to assist with clinical decision making to promote clinically indicated peripheral intravenous catheter (CIPIVC) insertion in the emergency department (ED) setting. Providing evidence for a uniform process could assist clinicians in a decision-making process for PIVC insertion. This could enable patients receive appropriate vascular access healthcare. Methods We performed a secondary analysis of data from a multicentre cohort of emergency department clinicians who performed PIVC insertion. We defined CIPIVC a priori as one used for a specific clinical treatment and or procedure such as prescribed intravenous (IV) fluids; prescribed IV medication; or IV contrast (for computerized tomography scans). We sought to refute or validate an assumption if the clinician performing or requesting the insertion decided the patient was >80% likely to need a PIVC. Using logistic regression, we derived a decision aid for CIPIVCs. Results In 817 patients undergoing PIVC insertion, we observed 68% of these to be CIPIVCs. Admitted patients were significantly more likely to have a CIPIVC, Odds Ratio (OR) = 3.05, 95% confidence interval (CI) = 2.17–4.30, p = <0.0001. Before insertion, patients who definitely needed IV fluids/medicines OR = 3.30, 95% CI = 2.02–5.39, p = <0.0001 and who definitely needed a contrast scan OR = 3.04, 95% CI = 1.15–8.03, p = 0.0250 were significantly more likely to have a device inserted for a clinical indication. Patients who presented with an existing vascular access device were more likely to have a new CIPIVC inserted for use OR = 4.35, 95% CI = 1.58–11.95, p = 0.0043. The clinician’s pre-procedural judgment of the likelihood of therapeutic use >80% was independently associated with CIPIVC; OR 3.16, 95% CI = 2.06–4.87, p<0.0001. The area under the receiver operating characteristic curve was 0.81, and at the best cut-off, the model had a specificity of 0.81, sensitivity of 0.71, a positive predictive value of 0.89 and negative predictive value of 0.57. Conclusions Using the derived decision aid, clinicians could ask:- “Does this patient need A-PIVC?” Clinicians can decide to insert a CIPIVCs when: (i) Admission to hospital is anticipated and when (ii) a Procedure requires a PIVC, e.g., computerised tomography scans and where an existing suitable vascular access device is not present and or; (iii) there is an indication for IV fluids and or medicines that cannot be tolerated enterally and are suitable for dilution in peripheral veins; and, (iv) the Clinician’s perceived likelihood of use is greater than 80%.Full Tex

Inhibiting Nitroso Related Methylation of Guanine Using Dietary Supplements and Flavonoids

Undergraduate Basi

Timescale of reduction of long-term phosphorus release from sediment in lakes

Publication history: Accepted - 19 May 2021; Published online - 25 May 2021.It is important for lake management and policy to estimate the timescale of recovery from long-term P release from sediment after a reduction in the external load. To provide a scientific basis for this, a condensed model was elaborated, applied and evaluated in four lakes. The model is based on first order kinetics, with an overall rate constant composed of the rate of diagenesis of labile P (kd,2) and rate of burial of P (kb) below an active sediment layer. Using the variation of P fractions in dated sediment cores, kd,2 varied from 0.0155 to 0.383 yr−1, kb from 0.0184 to 0.073 yr−1 and the overall rate constant from 0.0230 to 0.446 yr−1. The active layer depths, 8 to 29 cm, and kd,2 values are within the ranges found by others. The time for a 75% reduction (t75) of labile P in the active layer is 60 years in Lough Melvin, 3 in Ramor, 33 in Sheelin and 41 in Neagh, although P release is only important in Ramor and Neagh. Combining the kd,2 values with other estimates (mean 0.0981 yr−1, median 0.0426; n=14) produces a t75 value of less than 14 and 33 years. A review of other models indicates a timescale of one to two decades and from lake monitoring also of one to two decades. It is desirable to estimate the timescale directly in all lakes if sediment P release is important, but, generally, it should take between one and three decades.Environmental Protection Agency of Ireland; Department for Agriculture, Environment and Rural Affairs in Northern Irelan

Tools, clinical prediction rules, and algorithms for the insertion of peripheral intravenous catheters in adult hospitalized patients: A systematic scoping review of literature

Background: First time peripheral intravenous catheter (PIVC) insertion success is dependent on patient, clinician, and product factors. Failed PIVC insertion are an under-recognised clinical phenomenon. Aim: To provide a scoping review of decision aids for PIVC insertion including tools, clinical prediction rules, and algorithms (TRA) and their findings on factors associated with insertion success. Methods: In June 2016, a systematic literature search was performed using the medical subject heading of peripheral catheterization and tool* or rule* or algorithm*. Data extraction included clinician, patient and/or product variables associated with PIVC insertion success. Information about TRA reliability, validity, responsiveness and utility was also extracted. Results: We screened 36 studies, and included 13 for review. Seven papers reported insertion success ranging from 61%-90% (4,030 insertion attempts), six on validity and 5 on reliability, none on responsiveness and utility. Failed insertions were associated with obesity (OR 0.71-1.7, 95% CI 0.02-2.10, 2 studies) and smaller gauge PIVCs (OR 6.4, 95% CI 3.4-11.9, 1 study). Successful insertions were associated with visible veins (OR 0.87-3.63, 95% CI .17-6.32, 3 studies), or palpable veins (OR 0.79-5.05, 95% CI 0.74-18.64, 3 studies) inserters with greater procedural volume (OR 4.4, 95% CI 1.6-12.1, 1 study), or who predicted that insertion would be successful (OR 1.06, 95%CI 1.04-1.07, 1 study). Definitions of insertion difficulty are heterogeneous, from using time to insert to number of failed attempts. Conclusion: Few well-validated reliable TRAs exist for PIVC insertion. Patients would benefit from a validated, clinically pragmatic TRA that pairs insertion difficulty with clinician competency

Insertion of peripheral intravenous cannulae in the emergency department: Factors associated with first-time insertion success

Background - We sought to identify the reasons for peripheral intravenous cannulae insertion in the emergency department (ED), and the first-time insertion success rate, along with patient and clinician factors influencing this phenomenon. Methods - A prospective cohort study of patients requiring peripheral cannulae insertion in a tertiary ED. Clinical and clinician data were obtained. Results - A total 734 peripheral intravenous cannula (PIVC) insertions were included in the study where 460 insertions were analysed. The first-time insertion success incidence was 86%. The antecubital fossa (ACF) site accounted for over 50% of insertions. Multivariate logistic regression modelling to predict first-time insertion success for patient factors found: age Conclusions - Peripheral intravenous cannulation insertion success could be improved if performed by clinicians with greater procedural experience and increased perception of the likelihood of success. Some patient factors predict cannulation success: 'normal' body weight, visible vein/s and cubital fossa placement; venepuncture may be a cheaper alternative for others if intravenous therapy is not imperative

Lung ultrasound in heart failure: lessons from re-analysis of Lung Ultrasound 2011 database

: In the setting of patients presenting with shortness of breath to an Emergency Department a simple lung ultrasound protocol aimed at detecting pulmonary oedema has been shown to have diagnostic accuracy of 85%. This article reviews data from the original study, in an attempt to determine whether adjusting the protocol and/or interpretive criteria would improve results. : A large lung ultrasound project provided the dataset. Inter-rater and intertest discrepancies were reviewed. Then original stored images and comments were retrospectively analysed using alternate interpretive criteria. Specific variations included changing the number of B-lines required to define 'wet lung' and assessing other pleural line abnormalities. Where they had been acquired cardiac loops were reviewed in addition to the lung images. : The 204 original studies available were reviewed. Some disagreement could be attributed to inexperience and unclear definitions. Adjusting the number of B-lines did not improve diagnostic accuracy. All positive scans, with numerous B-lines were reviewed using more advanced diagnostic criteria (pleural line abnormalities) and the number of false positives was decreased. In cases where cardiac views were available, their inclusion was beneficial. : A simple lung ultrasound protocol to assess for 'wet lung' in patients presenting to Emergency Departments provides diagnostic accuracy of around 85% in the hands of relative novices. More advanced interpretation of the same_ultrasound images, and the addition of cardiac views, is likely to further improve diagnostic accuracy