Does the intravascular volume status in haemodialysis patients measured by inferior vena cava ultrasound correlate with bioimpedance spectroscopy?

AIMS AND OBJECTIVES: To evaluate the accuracy of traditional clinical predialytic fluid assessment by renal nurses and the efficacy of 2 additional fluid assessment methods focussing on the potential preventative effect for intradialytic hypotension (IDH). BACKGROUND: Predialytic fluid assessment remains a daily challenge for renal nurses, when aiming for adverse event free haemodialysis treatments. Adding further objective parameters obtained through noninvasive methods into pre- and intradialytic fluid assessment could potentially improve health outcomes for haemodialysis patients. DESIGN: Comparative, observational study of three fluid assessment methods on their reliability on volume status and correlation to clinical outcomes. METHODS: Clinical predialytic nursing fluid assessments in 30 haemodialysis patients were compared with additional initial bioimpedance spectroscopy (BIS) measurements, and 3 serial intradialytic ultrasound scans of the inferior vena cava (IVC-US) performed by a second renal nurse concurrently during the same session. A retrospective data analysis compared all measurements in each individual for the predictive value for IDH. A STROBE checklist for observational cohort studies was used for the reporting of results. RESULTS: Seven subjects experienced episodes of symptomatic intradialytic hypotension (S-IDH), which would have been anticipated by IVC-US or by BIS in 5 patients (71%). Using an algorithm to predict IDH would have provided a sensitivity of 100% and specificity of 95%. CONCLUSION: Both additional fluid assessment methods would have provided critical information before and during each haemodialysis session. Therefore, we consider them as being potentially effective for the prevention of intradialytic hypotension, with IVC-US being similar to BIS. RELEVANCE TO CLINICAL PRACTICE: Traditional clinical nursing fluid assessment methods in haemodialysis patients do not provide sufficient information to prevent episodes of IDH. Additional objective fluid assessment methods are useful and likely to lead to improved health outcomes in HD patients when applied by renal nurses. A combination of IVC-US, MAP and BIS has potential to reduce the risk of IDH events in HD patients significantly.

Prevalence of intradialytic hypotension, clinical symptoms and nursing interventions--a three-months, prospective study of 3818 haemodialysis sessions.

BACKGROUND: Intradialytic hypotension (IDH) is considered one of the most frequent complications of haemodialysis with an estimated prevalence of 20-50 %, but studies investigating its exact prevalence are scarce. A complicating factor is that several definitions of IDH are used. The goal of this study was, to assess the prevalence of IDH, primarily in reference to the European Best Practice Guideline (EBPG) on haemodynamic instability: A decrease in systolic blood pressure (SBP) ≥20 mmHg or in mean arterial pressure (MAP) ≥10 mmHg associated with a clinical event and the need for nursing intervention. METHODS: During 3 months we prospectively collected haemodynamic data, clinical events, and nursing interventions of 3818 haemodialysis sessions from 124 prevalent patients who dialyzed with constant ultrafiltration rate and dialysate conductivity. Patients were considered as having frequent IDH if it occurred in >20 % of dialysis sessions. RESULTS: Decreases in SBP ≥20 mmHg or MAP ≥10 mmHg occurred in 77.7 %, clinical symptoms occurred in 21.4 %, and nursing interventions were performed in 8.5 % of dialysis sessions. Dialysis hypotension according to the full EBPG definition occurred in only 6.7 % of dialysis sessions. Eight percent of patients had frequent IDH. CONCLUSIONS: The prevalence of IDH according to the EBPG definition is low. The dominant determinant of the EBPG definition was nursing intervention since this was the component with the lowest prevalence. IDH seems to be less common than indicated in the literature but a proper comparison with previous studies is complicated by the lack of a uniform definition.

Assessment and management of the septic patient: part 2.

Sepsis has gained increasing publicity in recent years, and there is now a strong focus of clinical education and training following the Surviving Sepsis Campaign. The assessment and management of a septic patients is far from simple and requires a systematic approach in both identifying and managing the condition. This second part explores sepsis care bundles and the research that underpins each of the interventions. These discussions will enable nurses to understand why each component of the sepsis care bundle is important and thus enable them to rapidly prioritise care, as early effective interventions have been shown to optimise patient outcomes.

Effects of the amount of rice in meals on postprandial blood pressure in older people with postprandial hypotension: a within-subjects design.

AIMS AND OBJECTIVES: To determine the effect of the amount of rice carbohydrates consumed during mealtime on the extent of decrease in postprandial blood pressure in older people with postprandial hypotension. BACKGROUND: The incidence of postprandial hypotension is as high as 74% in older people with hypertension. DESIGN: A within-subjects repeated measures design was used. METHODS: Thirty-nine older people in nursing homes received a full serving and a half-serving of rice on two separate days, in random order blood pressure and heart rate were measured before each meal and every 15 minutes for a total of 120 minutes after each meal. Data were analysed using repeated measures analysis of variance and the paired t-test with a Bonferroni adjustment using IBM spss version 19.0. RESULTS: The control and intervention conditions yielded significantly different patterns in systolic blood pressure and diastolic blood pressure. Postprandial hypotension was less frequent under the intervention condition; however, decrease in rice intake did not significantly affect heart rate. CONCLUSION: Reducing the amount of rice intake per meal prevents postprandial blood pressure decreases in the older people. Small and frequent meals with decreased carbohydrate content are recommended to prevent postprandial hypotension and its complications in the older people. RELEVANCE TO CLINICAL PRACTICE: Patients, dieticians and caregivers of older patients should be aware of the importance of diet, especially of decreasing the amount of carbohydrate in a meal. Smaller and more frequent meals are recommended for older people to slow gastric emptying.

Pathophysiology of the Cardiovascular System and Neonatal Hypotension.

Hypotension is common in low birth weight neonates and less common in term newborns and is associated with significant morbidity and mortality. Determining an adequate blood pressure in neonates remains challenging for the neonatal nurse because of the lack of agreed-upon norms. Values for determining norms for blood pressure at varying gestational and postnatal ages are based on empirical data. Understanding cardiovascular pathophysiology, potential causes of hypotension, and assessment of adequate perfusion in the neonatal population is important and can assist the neonatal nurse in the evaluation of effective blood pressure. This article reviews cardiovascular pathophysiology as it relates to blood pressure and discusses potential causes of hypotension in the term and preterm neonate. Variation in management of hypotension across centers is discussed. Underlying causes and pathophysiology of hypotension in the neonate are described.

Vasopressin for the treatment of neonatal hypotension.

Vasopressin (pitressin), also known as arginine vasopressin (AVP), is an antidiuretic hormone formed in the hypothalamus and secreted from the posterior pituitary gland. Various forms of exogenous vasopressin exist and have been used in neonates to treat conditions such as diabetes insipidus. Vasopressin has also been studied on a limited basis for use in the treatment of catecholamine-resistant hypotension in vasodilatory shock. Hypotension is a significant problem resulting in increased morbidity in preterm, septic, and postsurgical neonates. This article will discuss the role of vasopressin and its use as a therapeutic agent in the treatment of hypotension in the neonate.

Blood pressure support in the very low-birth-weight infant during the first week of life.

The immature cardiovascular system of very preterm infants predisposes them to low systemic blood flow during the first week of life, a state that may be damaging to multiple organ systems. There are many treatment strategies for the maintenance of cardiovascular equilibrium in these infants, each with its own advantages and risks. Caregivers are responsible for assessing the circulatory status of each patient and evaluating the effectiveness of interventions aimed at maintaining adequate systemic blood flow. Therefore, it is important to have an understanding of the mechanics of transitional circulation, the relationship between blood pressure and systemic blood flow, and the therapies used to treat infants with compromised organ perfusion.

Risk factors associated with pressure ulcer development in critically ill traumatic spinal cord injury patients.

Critically ill spinal cord injury (SCI) patients are at high risk for pressure ulcers. Research is needed to identify risk factors for pressure ulcers. The aim of this study was to investigate risk factors and outcomes of pressure ulcers in critically ill SCI patients. This is a retrospective cohort study. Data were gathered from medical records of adult patients with SCI admitted to surgical intensive care units. Ninety-four SCI patients participated in this study. Clinical variables associated with pressure ulcers were as follows: fecal management systems, incontinence, acidosis, support surfaces, steroids, and additional equipment. Hypotension was the strongest predictor of pressure ulcers. Nursing interventions may address risk factors and improve patient outcomes.

New NANN Practice Guideline: the management of hypotension in the very-low-birth-weight infant.

The Management of Hypotension in the Very-Low-Birth-Weight Infant: Guideline for Practice, developed by Lyn Vargo, PhD, RN, NNP-BC, and Istvan Seri, MD, PhD, in 2011 under the auspices of the National Association of Neonatal Nurse Practitioners, focuses on the challenging topic of clinical management of systemic hypotension in the very low-birth-weight (VLBW) infant during the first 3 days of postnatal life. The recommendations and rationale in the excerpt below from the complete online publication are based on the best evidence available through both neonatal research and consultation of experts on the subject. They suggest a conservative, evidence-based treatment approach for the management of hypotension in the VLBW infant during the first 3 days of postnatal life that is logical, safe, and physiologically sound. The insufficient fund of knowledge on transitional cardiovascular physiology in general and pathophysiology in particular makes establishment of strict guidelines on the treatment of hypotension in VLBW neonates impossible. What becomes clear when presenting the evidence is how much more we need to know. Readers are strongly encouraged to refer to the complete text of the guideline, which has been endorsed by the American Academy of Pediatrics, for further understanding of this complex topic. The guideline is available free of charge at www.nann.org (click on Guidelines in the Education section).

How to ensure observations lead to prompt identification and management of hypotension.

Hypotension is blood pressure that is abnormallylowand is a medical emergency, requiring rapid treatment and identification of the cause. Failure to manage this clinical sign can lead to a poor prognosis. This article describes the causes and management of hypotension.

How to ensure patient observations lead to effective management of bradycardia.

Bradycardia can be a normal physiological sign in fit young adults. However, in acute illness it may indicate life threatening heart block or precede asystole. This article outlines the assessment and management of patients with this condition.

Rapid Ultrasound for Shock and Hypotension: A Clinical Update for the Advanced Practice Provider: Part 1.

The Rapid Ultrasound for Shock and Hypotension (RUSH) examination is used for patients with hypotension without clear cause or undifferentiated hypotension. In the emergency department setting, clinicians may perform the RUSH examination to supplement the physical assessment and differentiate the diagnosis of hypovolemic, obstructive, cardiogenic, and distributive forms of shock. The key elements of the RUSH examination are the pump, tank, and pipes, meaning potentially causes of the hypotension are examined within the heart, vascular volume and integrity, and the vessels themselves. Clinicians follow a systemic protocol to seeking evidence of specific conditions including heart failure exacerbation, cardiac tamponade, pleural effusion, pneumothorax, abdominal aortic aneurysm, and deep vein thrombosis. Because ultrasonography is a user-dependent skill, the advanced practice nurse in the emergency department should be educated regarding the RUSH protocol and prepared to implement the examination.

[Complications of the hemodialysis procedure in acute renal failure patients: nursing interventions]. / Complicações do procedimento hemodialítico em pacientes com insuficiência renal aguda: intervenções de enfermagem.

This retrospective study has identified both the prevalence of complications during hemodialitic treatment in patients carrying acute renal failure (ARF) in an intensive care unit of a university hospital and the nursing conduct performed during those episodes. We have assessed sixty-five (282 sessions) records of ARF patients who underwent renal replacement therapy and presented complications during hemodialysis sessions. We have noticed that the most prevalent intradialitic complications were: arterial hypotension (35%), hypothermia (29%), and lack of flow in the vascular access (24.1%). The nursing interventions prioritized during episodes of clinical complications involved clinical assessment (66.8%) and evaluation of patients' consciousness level (59.9%). The search for nursing procedures that are suitable to different situations experienced by patients during hemodialysis, as well as the continuing education of the nursing team are actions that may minimize the intercurrence rate.

Clinical management of intradialytic hypotension: survey results.

Intradialytic hypotension (IDH) is one of the most common complications of hemodialysis treatment. Incidence of IDH varies from 10% to 50% of hemodialysis treatments. Numerous publications address the pathophysiology, effect of frequent episodes, and clinical management of IDH, but no recent publication has studied how IDH is managed in dialysis clinics. Interviews and a mail survey were conducted to develop a better understanding of the clinical issues and concerns surrounding the management of hemodialysis patients who experience episodes of IDH. Results of the survey indicate that IDH is prevalent and that clinical management is protocol--driven and consistent with treatment recommendations in the literature.