The efficacy of renal angioplasty in patients with renal artery stenosis and flash oedema or congestive heart failure: a systematic review.

AIMS: Recent randomized controlled trials have reported that angioplasty does not have a beneficial effect compared with pharmacological treatment on blood pressure and renal function in patients with atherosclerotic renal artery stenosis (RAS). We aimed to explore systematically the evidence that angioplasty is effective in subgroups of patients with RAS and either flash pulmonary oedema or congestive heart failure (CHF) and renal insufficiency. METHODS AND RESULTS: We searched online databases (PubMed and ClinicalTrials.gov) and references of included articles. We included 25 articles describing 79 patients with RAS and flash oedema and seven articles describing 94 patients with RAS, CHF, and renal insufficiency. According to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, the quality of the evidence was, at best, low. Seventy-six per cent of patients with flash oedema did not have any recurrence after angioplasty. Recurrence of symptoms was associated with either restenosis of the renal artery or cardiac arrhythmias in all patients. In the patients with CHF and renal insufficiency, the severity of heart failure symptoms, expressed as New York Heart Association (NYHA) functional class, improved after angioplasty in all included articles. CONCLUSION: The evidence included in this systematic review justifies a weak recommendation in favour of angioplasty in patients with atherosclerotic RAS and either flash pulmonary oedema or CHF and renal insufficiency.

The role of nurses in the recognition and treatment of patients with sepsis in the emergency department: a prospective before-and-after intervention study.

BACKGROUND: In 2004, the Surviving Sepsis Campaign (SSC), a global initiative to reduce mortality from sepsis, was launched. Although the SSC supplies tools to measure and improve the quality of care for patients with sepsis, effective implementation remains troublesome and no recommendations concerning the role of nurses are given. OBJECTIVES: To determine the effects of a multifaceted implementation program including the introduction of a nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback. DESIGN AND SETTING: A prospective before-and-after intervention study conducted in the emergency department (ED) of a university hospital in the Netherlands. PARTICIPANTS: Adult patients (≥16 years old) visiting the ED because of a known or suspected infection to whom two or more of the extended systemic inflammatory response syndrome (SIRS) criteria apply. METHODS: We measured compliance with six bundled SSC recommendations for early recognition and treatment of patients with sepsis: measure serum lactate within 6h, obtain two blood cultures before starting antibiotics, take a chest radiograph, take urine for urinalysis and culture, start antibiotics within 3h, and hospitalize or discharge the patient within 3h. RESULTS: A total of 825 patients were included in the study. Compliance with the complete bundle significantly improved from 3.5% at baseline to 12.4% after our entire implementation program was put in place. The completion of four of six individual elements improved significantly, namely: measure serum lactate (improved from 23% to 80%), take a chest radiograph (from 67% to 83%), take urine for urinalysis and culture (from 49% to 67%), and start antibiotics within 3h (from 38% to 56%). The mean number of performed bundle elements improved significantly from 3.0 elements at baseline to 4.2 elements after intervention [1.2; 95% confidence interval=0.9-1.5]. CONCLUSIONS: Early recognition of sepsis in patients presenting to the ED and compliance with SSC recommendations significantly improved after the introduction of a predominantly nurse-driven, care bundle based, sepsis protocol followed by training and performance feedback.