Safety of arteriovenous fistulae and grafts for continuous renal replacement therapy: The Michigan experience

Introduction: Arteriovenous fistula or graft (AVF/AVG) use is widely considered contraindicated for continuous renal replacement therapy (CRRT), yet insertion of hemodialysis (HD) catheters can carry high complication risk in critically ill end‐stage renal disease (ESRD) patients.Methods: Single‐center analysis of 48 consecutive hospitalized ESRD patients on maintenance HD who underwent CRRT using AVF/AVG from 2012 to 2013. Primary outcome was access‐related complications.Findings: Mean age was 60 years, 48% were male, and 88% required vasopressor support. Median duration of AVF/AVG use for CRRT was 4 days (range 1–34). Ten (21%) patients had access complications (5 bleeding, 5 infiltration, 1 thrombosis); 5 (10.4%) required catheter placement. Overall 31 (65%) patients survived to hospital discharge and AVF/AVG access was functional at the time of discharge in 29 (94%) patients.Discussion: In our experience, use of AVF/AVG for CRRT can be performed with a low serious complication rate and low risk of access loss, potentially avoiding catheter‐related complications.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141192/1/hdi12550_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/141192/2/hdi12550.pd

Optimal interval and duration of CAM-ICU assessments for delirium detection after cardiac surgery

STUDY OBJECTIVE: Our goal was to determine when postoperative delirium first occurs, and to assess evaluation strategies that reliably detect delirium with lowest frequency of testing. DESIGN: This was a retrospective study that used a database from a five-center randomized trial. SETTING: Postoperative cardiothoracic ICU and surgical wards. PARTICIPANT: Adults scheduled for elective coronary artery bypass and/or valve surgery. INTERVENTION AND MEASUREMENTS: Postoperative delirium was assessed using CAM-ICU questionnaires twice daily for 5 days or until hospital discharge. Data were analyzed using frequency tables and Kaplan-Meier time-to-event estimators, the latter being used to summarize time to first positive CAM-ICU over POD1-5 for all patients for various evaluation strategies, including all assessments, only morning assessment, and only afternoon assessments. Sensitivity for various strategies were compared using McNemar\u27s test for paired proportions. MAIN RESULTS: A total of 95 of 788 patients (12% [95% CI, 10% to 15%]) had at least 1 episode of delirium within the first 5 postoperative days. Among all patients with delirium, 65% were identified by the end of the first postoperative day. Delirium was detected more often in the mornings (10% of patients) than evenings (7% of patients). Compared to delirium assessments twice daily for five days, we found that twice daily assessments for 4 days detected an estimated 97% (95% CI 91%, 99%) of delirium. Measurements twice daily for three days detected 90% (82%, 95%) of delirium. CONCLUSIONS: Postoperative delirium is common, and CAM-ICU assessments twice daily for 4 days, versus 5 days, detects nearly all delirium with 20% fewer assessments. Four days of assessment may usually be sufficient for clinical and research purposes

Inadvertent arterial insertion of a central venous catheter: delayed recognition with abrupt changes in pressure waveform during surgery -A case report-

We present a case of inadvertent arterial insertion of a central venous catheter, identified during a pericardiectomy procedure after observing abrupt changes in pressure waveform and confirmed via arterial blood gas analysis and transesophageal echocardiography. Central venous pressure measurement was initially 20 mmHg in supine, and then elevated to 30-40 mmHg in right lateral decubitus, presumably resulting from constrictive physiology of pericarditis. The pressure waveforms, however, abruptly changed from a venous to an arterial waveform during surgery. When visual discrimination between arterial and venous blood regurgitation is unreliable, anesthesiologists should confirm that using all the available methods one has on the scene, especially after at least two unsuccessful attempts or in patients with advanced age or clinical conditions resulting in jugular venous dilation. To prevent arterial catheterization, one should limit the leftward rotation of the head by <40° and consider using ultrasound-guided method after more than two unsuccessful attempts

Methodology for integrated socio-economic assessment of offshore platforms : towards facilitation of the implementation of the marine strategy framework directive

In this paper a Methodology for Integrated Socio-Economic Assessment (MISEA) of the viability and sustainability of different designs of Multi-Use Offshore Platforms (MUOPs) is presented. MUOPs are designed for multi-use of ocean space for energy extraction (wind power production and wave energy), aquaculture and transport maritime services. The developed methodology allows identification, valuation and assessment of: the potential range of impacts of a number of feasible designs of MUOP investments, and the likely responses of those impacted by the investment project. This methodology provides decision-makers with a valuable decision tool to assess whether a MUOP project increases the overall social welfare and hence should be undertaken, under alternative specifications regarding its design, the discount rate and the stream of net benefits, if a Cost-Benefit Analysis (CBA) is to be followed or sensitivity analysis of selected criteria in a Multi-Criteria Decision Analysis (MCDA) framework. Such a methodology is also crucial for facilitating of the implementation of the Marine Strategy Framework Directive (MSFD adopted in June 2008) that aims to achieve good environmental status of the EU's marine waters by 2020 and to protect the resource base upon which marine-related economic and social activities depend. According to the MSFD each member state must draw up a program of cost-effective measures, while prior to any new measure an impact assessment which contains a detailed cost-benefit analysis of the proposed measures is required

Boosting Blue Growth in a Mild Sea: Analysis of the Synergies Produced by a Multi-Purpose Offshore Installation in the Northern Adriatic, Italy

In the near future, the oceans will be subjected to a massive development of marine infrastructures, including offshore wind, tidal and wave energy farms and constructions for marine aquaculture. The development of these facilities will unavoidably exert environmental pressures on marine ecosystems. It is therefore crucial that the economic costs, the use of marine space and the environmental impacts of these activities remain within acceptable limits. Moreover, the installation of arrays of wave energy devices is still far from being economically feasible due to many combined aspects, such as immature technologies for energy conversion, local energy storage and moorings. Therefore, multi-purpose solutions combining renewable energy from the sea (wind, wave, tide), aquaculture and transportation facilities can be considered as a challenging, yet advantageous, way to boost blue growth. This would be due to the sharing of the costs of installation and using the produced energy locally to feed the different functionalities and optimizing marine spatial planning. This paper focuses on the synergies that may be produced by a multi-purpose offshore installation in a relatively calm sea, i.e., the Northern Adriatic Sea, Italy, and specifically offshore Venice. It analyzes the combination of aquaculture, energy production from wind and waves, and energy storage or transfer. Alternative solutions are evaluated based on specific criteria, including the maturity of the technology, the environmental impact, the induced risks and the costs. Based on expert judgment, the alternatives are ranked and a preliminary layout of the selected multi-purpose installation for the case study is proposed, to further allow the exploitation of the synergies among different functionalities

withdrawn 2017 hrs ehra ecas aphrs solaece expert consensus statement on catheter and surgical ablation of atrial fibrillation

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International evidence-based recommendations on ultrasound-guided vascular access

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