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Schoch M, Fielding C, Marticorena RM, Smith GE, Sinclair PM, Iglesias R, Bennett PN. Barriers and facilitators to vascular access point-of-care ultrasound in haemodialysis: An international survey of haemodialysis clinicians. J Ren Care 2024. [PMID: 38808962 DOI: 10.1111/jorc.12503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/14/2024] [Accepted: 05/15/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Utilising point-of-care ultrasound for assessment and cannulation of vascular access in people receiving haemodialysis has shown positive clinical results. Nonetheless, there is variation in how renal health care professionals worldwide embrace this method, and there's a lack of research on the factors that promote or hinder its adoption. OBJECTIVES To explore regional differences, and barriers and facilitators, to the use of point-of-care ultrasound for assessment and cannulation of vascular access in haemodialysis. DESIGN Exploratory descriptive cross-sectional web-based survey. PARTICIPANTS Healthcare clinicians working in haemodialysis responsible for cannulation of arteriovenous fistula or grafts. RESULTS The survey was completed by 645 health care clinicians from 38 countries. 75% to 93% of respondents from Australia/New Zealand, Canada, Europe and United Kingdom/Ireland reported access to ultrasound, compared to 26% (n = 43/167) from the United States respondent's reported lower levels of ultrasound training than other regions. Facilitators for using ultrasound were: the availability of ultrasound training (87%, n = 558), to reduce miscannulations (76%, n = 255/336) and to improve patient outcomes (73%, n = 246/336). Point-of-care ultrasound barriers were lack of access to ultrasound education (82%, n = 196/239), lack of ultrasound machines (33%, n = 212/645) or believing that ultrasound was someone else's role (38%, n = 29/86). CONCLUSIONS This study revealed national and regional differences related to haemodialysis point-of-care ultrasound. Understanding the regions requiring more education and implementation of ultrasound and what motivates staff, or deters from using ultrasound, is crucial for effectiveness of future implementation and workplace change initiatives.
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Affiliation(s)
- Monica Schoch
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Catherine Fielding
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rosa M Marticorena
- Nephrology Programme, Sir William Osler Health System, Brampton, Ontario, Canada
| | - George E Smith
- Academic Vascular Surgery Unit, Hull York Medical School, Hull, UK
| | - Peter M Sinclair
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | | | - Paul N Bennett
- School of Nursing and Midwifery, Griffith Health, Griffith University, Brisbane, Queensland, Australia
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Cook DL, Patel S, Nee R, Little DJ, Cohen SD, Yuan CM. Point-of-Care Ultrasound Use in Nephrology: A Survey of Nephrology Program Directors, Fellows, and Fellowship Graduates. Kidney Med 2023; 5:100601. [PMID: 36941846 PMCID: PMC10024220 DOI: 10.1016/j.xkme.2023.100601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Rationale & Objective Adoption of point-of-care ultrasound (POCUS) into nephrology practice has been relatively slow. We surveyed US nephrology program directors, their fellows, and graduates from a single training program regarding current/planned POCUS training, clinical use, and barriers to training and use. Study Design Anonymous, online survey. Setting & Participants All US nephrology program directors (n=151), their fellows (academic year 2021-2022), and 89/90 graduates (1980-2021) of the Walter Reed Nephrology Program. Analytical Approach Descriptive. Results 46% (69/151) of program directors and 33% (118/361) of their fellows responded. Response rate was 62% (55/89) for Walter Reed graduates. 51% of program directors offered POCUS training, most commonly bedside training in non-POCUS oriented rotations (71%), didactic lectures (68%), and simulation (43%). 46% of fellows reported receiving POCUS training, but of these, many reported not being sufficiently trained/not confident in kidney (56%), bladder (50%), and inferior vena cava assessment (46%). Common barriers to training reported by program directors were not enough trained faculty (78%), themselves not being sufficiently trained (55%), and equipment expense (51%). 64% of program directors and 55% of fellows reported <10% of faculty were able to perform POCUS. 64% of fellows reported having too little POCUS training. 72% of program directors and 77% of graduates felt POCUS should be incorporated into the fellowship curriculum. 59% of fellows and 61% of graduates desired hands-on POCUS training rather than didactic lectures or simulation. Limitations Loss of respondents as program directors and fellows progressed through the survey. Conclusions Nephrology program directors, fellows, and graduates surveyed want POCUS training incorporated into the fellowship curriculum. No group felt sufficiently trained to confidently perform POCUS, and the major barrier to training was lack of sufficiently trained faculty. This highlights the need to "train the trainers" before POCUS can be fully integrated into fellowship training and regularly used in nephrology practice.
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Affiliation(s)
- David L. Cook
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Samir Patel
- Washington DC VA Medical Center, Washington, District of Columbia
| | - Robert Nee
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Dustin J. Little
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Scott D. Cohen
- Washington DC VA Medical Center, Washington, District of Columbia
| | - Christina M. Yuan
- Walter Reed National Military Medical Center, Bethesda, Maryland
- Address for Correspondence: Christina M. Yuan, MD, Nephrology SVC, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889.
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Romero-González G, Manrique J, Slon-Roblero MF, Husain-Syed F, De la Espriella R, Ferrari F, Bover J, Ortiz A, Ronco C. PoCUS in nephrology: a new tool to improve our diagnostic skills. Clin Kidney J 2023; 16:218-229. [PMID: 36755847 PMCID: PMC9900589 DOI: 10.1093/ckj/sfac203] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Indexed: 11/14/2022] Open
Abstract
Point-of-Care Ultrasonography (PoCUS) aims to include a fifth pillar (insonation) in the classical physical examination in order to obtain images to answer specific questions by the clinician at the patient's bedside, allowing rapid identification of structural or functional abnormalities, enabling more accurate volume assessment and supporting diagnosis, as well as guiding procedures. In recent years, PoCUS has started becoming a valuable tool in day-to-day clinical practice, adopted by healthcare professionals from various medical specialties, never replacing physical examination but improving patient and medical care and experience. Renal patients represent a wide range of diseases, which lends PoCUS a special role as a valuable tool in different scenarios, not only for volume-related information but also for the assessment of a wide range of acute and chronic conditions, enhancing the sensitivity of conventional physical examination in nephrology. PoCUS in the hands of a nephrologist is a precision medicine tool.
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Affiliation(s)
- Gregorio Romero-González
- Nephrology Department, University Hospital Germans Trias I Pujol, Badalona, Spain
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
- International Renal Research Institute of Vicenza, Vicenza, Italy
| | - Joaquin Manrique
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
- Nephrology Department, University Hospital of Navarra, Pamplona, Spain
| | - María F Slon-Roblero
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
- Nephrology Department, University Hospital of Navarra, Pamplona, Spain
| | - Faeq Husain-Syed
- Department of Medicine, University of Virginia School of Medicine, 1300 Jefferson Park Avenue, Charlottesville, USA
- Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Klinikstrasse, Giessen, Germany
| | | | | | - Jordi Bover
- Nephrology Department, University Hospital Germans Trias I Pujol, Badalona, Spain
- REMAR-IGTP Group, Research Institute Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IISFundacion Jimenez Diaz UAM, Madrid, Spain
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, Vicenza, Italy
- Professor of Medicine - University of Padova, Padova, Italy
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
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4
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Vigotti FN, Di Benedetto C, Fop F, Bianco S, Bilucaglia D, Cesano G. Lung ultrasonography performed by nephrologist: COVID-19 as an opportunity to reveal ultrasound's full potential and usefulness in the dialysis room. Clin Kidney J 2022; 16:541-548. [PMID: 36865007 PMCID: PMC9972800 DOI: 10.1093/ckj/sfac250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Indexed: 12/23/2022] Open
Abstract
Background Interest in point-of-care ultrasound (POCUS) and lung ultrasound (LUS) is growing in the nephrology and dialysis field, and the number of nephrologists skilled in what is proving to be the "5th pillar of bedside physical examination" is increasing. Patients on hemodialysis (HD) are at high risk of contracting severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) and developing coronavirus disease 2019 (COVID-19) serious complications. Despite this, to our knowledge there are no studies to date that show the role of LUS in this setting, while there are many in the emergency room, where LUS proved to be an important tool, providing risk stratification and guiding management strategies and resource allocation. Therefore, it is not clear whether the usefulness and cut-offs of LUS highlighted in studies in the general population are reliable in dialysis, or whether variations, precautions and adjustments to this specific situation are necessary. Methods This was a 1-year monocentric prospective observational cohort study of 56 HD patients with COVID-19. Patients underwent a monitoring protocol that included at first evaluation bedside LUS, using a 12-scan scoring system, by the same nephrologist. All data were prospectively and systematically collected. Outcomes. hospitalization rate, combined outcome [non-invasive ventilation (NIV + death)], mortality. Descriptive variables are presented as medians (interquartile range), or percentage. Univariate and multivariate analysis, as well as Kaplan-Meier (K-M) survival curves, were carried out. P was fixed at .05. Results Median age was 78 years, 90% had at least one comorbidity (46% diabetics), 55% were hospitalized and 23% deaths. Median duration of disease was 23 days (14-34). A LUS score ≥11 represented a 13-fold risk of hospitalization, a 16.5-fold risk of combined outcome (NIV + death) vs risk factors such as age [odds ratio (OR) 1.6], diabetes (OR 1.2), male sex (OR 1.3) and obesity (OR 1.25), and a 7.7-fold risk of mortality. In the logistic regression, LUS score ≥11 is associated with the combined outcome with a hazard ratio (HR) of 6.1 vs inflammations indices such as CRP ≥9 mg/dL (HR 5.5) and interleukin-6 (IL-6) ≥62 pg/mL (HR 5.4). In K-M curves, survival drops significantly with LUS score above 11. Conclusions In our experience of COVID-19 HD patients, LUS appeared to be an effective and easy tool, predicting the need for NIV and mortality better than "classic" known COVID-19 risk factors such as age, diabetes, male sex and obesity, and even better than inflammations indices such as CRP and IL-6. These results are consistent with those of the studies in the emergency room setting, but with a lower LUS score cut-off (11 vs 16-18). This is probably due to the higher global frailty and peculiarity of HD population, and emphasizes how nephrologists should themselves use LUS and POCUS as a part of their everyday clinical practice, adapting it to the peculiarity of the HD ward.
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Affiliation(s)
| | - Carlo Di Benedetto
- University of Turin, Nephrology and Dialysis, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Fabrizio Fop
- University of Turin, Nephrology and Dialysis, Molinette Hospital, ASO Città della Salute e della Scienza, Turin, Italy
| | - Simona Bianco
- Nephrology and Dialysis, Martini Hospital, ASL Città di Torino, Turin, Italy
| | | | - Giulio Cesano
- Nephrology and Dialysis, Martini Hospital, ASL Città di Torino, Turin, Italy
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Greenberg KI, Pourafshar N, Choi MJ. Current Trends and Challenges in Nephrology Fellowship Training: Expansion of Education in Home Dialysis, Palliative Care, and Point-of-Care Ultrasound. Adv Chronic Kidney Dis 2022; 29:510-515. [PMID: 36371114 DOI: 10.1053/j.ackd.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/15/2022] [Accepted: 07/13/2022] [Indexed: 11/11/2022]
Abstract
Nephrology education has changed significantly since the first nephrology fellowship programs were established in the United States in the 1950s and 1960s. The past several years have seen increased opportunities for subspecialization in areas such as interventional nephrology, onconephrology, and glomerular disease. Notable trends in fellowship curricula include the expansion of education in home dialysis and palliative care, driven by policy changes and focus on patient-centered care. In addition, point-of-care ultrasound has garnered significant interest due to its potential to provide diagnostic information that improves patient care. An important area that remains largely unaddressed appears to be education about the business and administrative aspects of nephrology. Meanwhile, the importance of training in hemodialysis catheter placement and kidney biopsy has come into question due to the small proportion of nephrologists performing these procedures today. Nephrology fellowship programs should strive to tailor their curriculum to meet the interests and needs of individual fellows.
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Abstract
Volume status assessment is a critical but challenging clinical skill and is especially important for the management of patients in the emergency department, intensive care unit, and dialysis unit where accurate intravascular assessment is necessary to guide appropriate fluid management. Assessment of volume status is subjective and can vary from provider to provider, posing clinical dilemmas. Traditional non-invasive methods of volume assessment include assessment of skin turgor, axillary sweat, peripheral edema, pulmonary crackles, orthostatic vital signs, and jugular venous distension. Invasive assessments of volume status include direct measurement of central venous pressure and pulmonary artery pressures. Each of these has their own limitations, challenges, and pitfalls and were often validated based on small cohorts with questionable comparators. In the past 30 years, the increased availability, progressive miniaturization, and falling price of ultrasound devices has made point of care ultrasound (POCUS) widely available. Emerging evidence base and increased uptake across multiple subspecialities has facilitated the adoption of this technology. POCUS is now widely available, relatively inexpensive, free of ionizing radiation, and can help providers make medical decisions with more precision. POCUS is not intended to replace the physical exam, but rather to complement clinical assessment, guiding providers to give thorough and accurate clinical care to their patients. We should be mindful of the nascent literature supporting the use of POCUS and other limitations as uptake increases among providers and be wary not to use POCUS to substitute clinical judgement, but integrate ultrasonographic findings carefully with history and clinical examination.
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Affiliation(s)
- David Kearney
- Renal-Electrolyte Hypertension Division, University of Pennsylvania Philadelphia, PA
| | - Nathaniel Reisinger
- Renal-Electrolyte Hypertension Division, University of Pennsylvania Philadelphia, PA
| | - Sadichhya Lohani
- Renal-Electrolyte Hypertension Division, University of Pennsylvania Philadelphia, PA
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7
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Veitla V, Bhasin B. Focused Cardiac Assessment in Kidney Care. POCUS JOURNAL 2022; 7:45-50. [PMID: 36896102 PMCID: PMC9994304 DOI: 10.24908/pocus.v7ikidney.14996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Point of care ultrasonography (POCUS) is considered to be a very useful and informative extension of the bedside physical exam. The information obtained from POCUS allows for real time assessment for expedited decision making to improve efficiency in patient care and management. Many programs across the country are now incorporating POCUS into their training schedules to allow their residents, fellows, and faculty to gain competence in the techniques and varied clinical uses of POCUS [1-3]. In nephrology, POCUS has been used at the bedside for access planning, dialysis catheter placement, and to guide kidney biopsies to mention a few applications [4]. There is a wide scope for POCUS in nephrology in addition to kidney and bladder assessment. This includes focused cardiac ultrasound to evaluate the heart for structural and functional abnormalities and lung ultrasound as well. These bedside ultrasound assessments help with point of care management decisions pertaining to volume assessment in acute and chronic kidney disease, adjustment of ultrafiltration goals in dialysis patients, and evaluation of hypotension and dyspnea.
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Affiliation(s)
- Vineet Veitla
- Division of Nephrology, Medical College of Wisconsin Milwaukee, WI
| | - Bhavna Bhasin
- Division of Nephrology, Medical College of Wisconsin Milwaukee, WI
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8
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Abstract
For those that have experienced how much point of care ultrasound can positively impact patient care, the potential of an organized point of care ultrasound program is moderated by the reality of building such a program from scratch. We have watched novice and intermediate users ride the roller coaster of ambition and reality checks at each of the hands-on skills sessions across the nation. The first climb occurs on the morning of Day 1. Anticipation grows over how hard it might be to learn this skill, then peaks and dips into the exhilaration of seeing success with what feels like minimal guidance. A comprehension of attainability takes over, and after each hands-on session, confidence climbs fast. Day 2 begins with the courage of some experience, and the anticipation of more success.
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9
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Dversdal RK, Northcutt NM, Ferre RM. Building and Maintaining an Ultrasound Program: It Takes a Village. Adv Chronic Kidney Dis 2021; 28:236-243. [PMID: 34906308 DOI: 10.1053/j.ackd.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/27/2021] [Accepted: 06/09/2021] [Indexed: 12/23/2022]
Abstract
Building and maintaining a successful point-of-care ultrasound program is a complex process that involves establishing an ecosystem between three unique but overlapping domains: ultrasound equipment, ultrasound users, and the health care system. By highlighting the different areas of focus and each of the key stakeholders and components, a group can ensure adequate attention is paid to all aspects of point-of-care ultrasound program development in nephrology.
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10
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Kim KH, Jung JY, Park JW, Lee MS, Lee YH. Operating bedside cardiac ultrasound program in emergency medicine residency: A retrospective observation study from the perspective of performance improvement. PLoS One 2021; 16:e0248710. [PMID: 33798217 PMCID: PMC8018668 DOI: 10.1371/journal.pone.0248710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 03/03/2021] [Indexed: 12/16/2022] Open
Abstract
Background Point-of-care ultrasound is one of useful diagnostic tools in emergency medicine practice and considerably depends on physician’s performance. This study was performed to evaluate performance improvements and favorable attitudes through structured cardiac ultrasound program for emergency medicine residents. Methods Retrospective observational study using the point-of-care ultrasound (PoCUS) database in one tertiary academic-teaching hospital emergency department has been conducted. Cardiac ultrasound education and rotation program has been implemented in emergency medicine residency program. Structured evaluation sheet for cardiac ultrasound and questionnaire toward PoCUS have been developed. An early-phase and a late-phase case were selected randomly for each participant. Two emergency medicine specialists with expertise in PoCUS evaluated saved images independently. We used a paired t-test to compare the performance score of each phase and the results of the questionnaire. Multivariable linear regression analysis was conducted to evaluate the association between the characteristics of participants and performance improvements. Results During the study period, a total of 1,652 bedside cardiac ultrasounds were administered. Forty-six examinations conducted by 23 emergency medicine residents were randomly selected for analysis. The performance score increased from 39.5 to 56.1 according to expert A and 45.3 to 62.9 according to expert B (p-value <0.01 for both). The average questionnaire score, which was analyzed for 17 participants, showed improvement from 18.9 to 20.7 (p-value <0.01). In multivariable linear regression analysis, younger age, higher early-phase score and higher confidence had a negative association with a greater improvement of performance, while the number of examinations had a positive association. Conclusions Bedside cardiac ultrasound performance and attitudes toward PoCUS have been improved through structured residency program.
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Affiliation(s)
- Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jae Yun Jung
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
- * E-mail:
| | - Joong Wan Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Min Sung Lee
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Yong Hee Lee
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea
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Point-of-Care Ultrasound for Evaluation of Systolic Heart Function in Outpatient Hemodialysis Units. Kidney Med 2021; 3:317-319. [PMID: 33851131 PMCID: PMC8039423 DOI: 10.1016/j.xkme.2020.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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12
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Martinez LC, Khan SF, Bowman BT. Approach to Electrolyte Abnormalities, Prerenal Azotemia, and Fluid Balance. Prim Care 2020; 47:555-569. [PMID: 33121628 DOI: 10.1016/j.pop.2020.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Volume and electrolyte evaluation and management is seen frequently in primary care practices. Some of the most common abnormalities encountered in outpatient practices are prerenal azotemia, dysnatremias, and altered potassium levels. Perturbations in volume or electrolyte concentrations can lead to serious organ dysfunction as well as hemodynamic collapse. This review focuses on the maintenance and regulation of intravascular volume and electrolytes, specifically sodium and potassium.
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Affiliation(s)
- Lisa C Martinez
- Florida Atlantic University, Charles E. Schmidt College of Medicine, 777 Glades Road, Boca Raton, FL 33431, USA.
| | - Sana F Khan
- University of Virginia School of Medicine, 1300 Jefferson Park Avenue, Charlottesville, VA 22903, USA
| | - Brendan T Bowman
- University of Virginia School of Medicine, 1300 Jefferson Park Avenue, Charlottesville, VA 22903, USA
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Vieira ALS, Pazeli Júnior JM, Bastos MG. Role of point-of-care ultrasound during the COVID-19 pandemic: our recommendations in the management of dialytic patients. Ultrasound J 2020; 12:30. [PMID: 32488686 PMCID: PMC7266651 DOI: 10.1186/s13089-020-00177-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/21/2020] [Indexed: 11/10/2022] Open
Abstract
COVID-19 is a viral disease due to the infection of the novel Corona virus SARS-CoV-2, that has rapidly spread in many countries until the World Health Organization declared the pandemic from March 11, 2020. Elderly patients and those affected by hypertension, diabetes mellitus, and chronic pulmonary and cardiovascular conditions are more susceptible to present more severe forms of COVID-19. These conditions are often represented in dialytic renal end-stage patients. Moreover, dialysis patients are more vulnerable to infection due to suppression of the immune system. Growing evidences, although still supported by few publications, are showing the potential utility of ultrasound in patients with COVID-19. In this review, we share our experience in using point-of-care ultrasound, particularly lung ultrasound, to indicate the probability of COVID-19 in patients with end-stage renal disease treated by hemodialysis. We also propose recommendations for the application of lung ultrasound, focused echocardiography and inferior vena cava ultrasound in the management of patients in hemodialysis.
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Affiliation(s)
- Ana Luisa Silveira Vieira
- Department of Nephrology, Santa Casa de Misericórdia de Barbacena and University of Medicine of Barbacena Department of Point of Care Ultrasound, Minas Gerais, Brazil.
| | - José Muniz Pazeli Júnior
- Department of Nephrology and Intensive Care Medicine, Santa Casa de Misericórdia de Barbacena and University of Medicine of Barbacena Department of Point of Care Ultrasound, Minas Gerais, Brazil
| | - Marcus Gomes Bastos
- Federal University of Juiz de Fora, Minas Gerais, Brazil
- Faculty at School of Medicine, UNIFAGOC and SUPREMA, Minas Gerais, Brazil
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14
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Wang PH, Lien WC. Point-of-care ultrasound in Management for Dyspneic Uremic Patients: a case report. BMC Nephrol 2019; 20:463. [PMID: 31830919 PMCID: PMC6909644 DOI: 10.1186/s12882-019-1654-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 12/02/2019] [Indexed: 12/23/2022] Open
Abstract
Background Point-of-Care Ultrasound (PoCUS) is considered as an extension of clinicians’ patient care and can be integrated into daily clinical practice. Dyspnea is a common presentation in uremic patients. With the aids of PoCUS and integrated assessments of lung, heart and inferior vena cava (IVC), the etiology of dyspnea in uremic patients can be determined earlier. Case presentation A 67-year-old woman presented with progressive shortness of breath and bilateral legs edema for 3 weeks. The laboratory data revealed marked elevated level of serum creatinine and blood urea. A large amount of pericardial effusion was timely detected by PoCUS. Uremic pericarditis was suspected. Emergent hemodialysis was initiated and her symptoms improved. Conclusions PoCUS is a noninvasive and cost-effective imaging modality and it has been popular in the emergency department (ED). In uremic patients presenting with dyspnea, the integration of PoCUS into traditional physical examinations help emergency physicians narrow down the differential diagnoses.
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Affiliation(s)
- Pei-Hsiu Wang
- Department of Emergency Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University,
- No.7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Wan-Ching Lien
- Department of Emergency Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University,
- No.7, Chung-Shan South Road, Taipei, 100, Taiwan.
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15
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Denault A, Canty D, Azzam M, Amir A, Gebhard CE. Whole body ultrasound in the operating room and intensive care unit. Korean J Anesthesiol 2019; 72:413-428. [PMID: 31159535 PMCID: PMC6781205 DOI: 10.4097/kja.19186] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/23/2019] [Indexed: 12/14/2022] Open
Abstract
Whole body ultrasound can be used to improve the speed and accuracy of evaluation of an increasing number of organ systems in the critically ill. Cardiac and abdominal ultrasound can be used to identify the mechanisms and etiology of hemodynamic instability. In hypoxemia or hypercarbia, lung ultrasound can rapidly identify the etiology of the condition with an accuracy that is equivalent to that of computed tomography. For encephalopathy, ocular ultrasound and transcranial Doppler can identify elevated intracranial pressure and midline shift. Renal and bladder ultrasound can identify the mechanisms and etiology of renal failure. Ultrasound can also improve the accuracy and safety of percutaneous procedures and should be currently used routinely for central vein catheterization and percutaneous tracheostomy.
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Affiliation(s)
- André Denault
- Department of Anesthesiology and Critical Care Medicine, Faculté de Médecine, Université de Montréal, Institut de Cardiologie de Montréal, and Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - David Canty
- Department of Surgery, University of Melbourne, Australia.,Department of Medicine, Monash Medical Centre, Monash University, Clayton, Melbourne, and Department of Anesthesia, Monash Medical Centre and Royal Melbourne Hospital, Victoria, Australia
| | - Milène Azzam
- Department of Anesthesiology, Jewish General Hospital, McGill University Faculty of Medicine, Montreal, QC, Canada
| | - Alexander Amir
- Department of Anesthesiology, Montreal General Hospital, McGill University Faculty of Medicine, Montreal, QC, Canada
| | - Caroline E Gebhard
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
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Mullangi S, Sozio SM, Hellmann DB, Martire C, Lohani S, Segal P, Shafi T. Integrative Point-of-Care Ultrasound Curriculum to Impart Diagnostic Skills Relevant to Nephrology. Am J Kidney Dis 2019; 73:894-896. [DOI: 10.1053/j.ajkd.2019.01.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/11/2019] [Indexed: 02/06/2023]
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Point-of-care ultrasound in end-stage kidney disease: beyond lung ultrasound. Curr Opin Nephrol Hypertens 2019; 27:487-496. [PMID: 30188387 DOI: 10.1097/mnh.0000000000000453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Following the miniaturization of ultrasound devices, point-of-care ultrasound (POCUS) has been proposed as a tool to enhance the value of physical examination in various clinical settings. The objective of this review is to describe the potential applications of POCUS in end-stage renal disease patients (ESRD). RECENT FINDINGS With basic training, the clinician can perform pulmonary, vascular, cardiac, and abdominal POCUS at the bedside of ESRD patients. Pulmonary ultrasound can be used to quantify pulmonary congestion and for the differential diagnosis of dyspnea. Ultrasound of the inferior vena cava combined with simple cardiac ultrasound can be used to promptly investigate the mechanism of hemodynamic instability. Vascular ultrasound can be used for troubleshooting of arteriovenous fistula problems and for catheter installation. Multiple potential applications of POCUS in the ESRD population are reviewed, including areas of future research. SUMMARY Acquiring basic skills in POCUS may improve patient care through the rapid identification of threats, improved diagnostic abilities for common symptoms, and safer procedures. The adoption of POCUS in undergraduate, internal medicine and nephrology training curriculums will likely lead to a gradual introduction of this technology in the care of ESRD patients.
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Nair D, Pivert KA, Baudy A, Thakar CV. Perceptions of nephrology among medical students and internal medicine residents: a national survey among institutions with nephrology exposure. BMC Nephrol 2019; 20:146. [PMID: 31035944 PMCID: PMC6489240 DOI: 10.1186/s12882-019-1289-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 03/10/2019] [Indexed: 12/28/2022] Open
Abstract
Background Fewer trainees are choosing to pursue nephrology. Only 60.1% of positions filled in the 2018 fellowship Match, which is concerning given the rising prevalence of end-stage kidney disease. Identifying factors influential in career choices is critical to inform focused approaches to recruit qualified applicants. Methods To understand perceptions of nephrology and assess factors influential in specialty choice among early career trainees, an anonymous survey was distributed to upper-level medical students and internal medicine residents at programs identified through the American Association of Medical Colleges (AAMC) and American Medical Association’s Fellowship and Residency Electronic Interactive Database (FREIDA). Results Of 4199 recipients, 644 (15.3%) participants responded, including 315 upper-level medical students, 308 residents, and three chief residents from 30 institutions. An interest in the subject was the most critical factor in selecting a specialty (92%). Other key factors included a suitable work-life balance (73%), access to mentors (70%), and subject exposure (66%). Lack of interest was the most frequently-cited reason to forgo a nephrology fellowship (79%), followed by concerns regarding remuneration (43%), work-life balance (39%), and subject exposure (32%). In free-text responses, several participants described frustration with managing patients on hemodialysis and desired combined training with specialties such as critical care. Respondents who had considered nephrology at any point cited an interest in physiology or interface with a mentor as key driving factors. Conclusions A lack of interest in and exposure to the subject, perceptions of poor earning potential and patient nonadherence, and concerns regarding work-life balance were influential in participants’ decisions to forgo nephrology training. Incorporating novel educational tools and broadening the scope of the nephrology elective, highlighting ongoing areas of clinical and research innovation, expanding opportunities for interdisciplinary collaboration and procedural skills, and cultivating strategies to reduce burnout may be useful areas on which to focus future recruitment efforts. Electronic supplementary material The online version of this article (10.1186/s12882-019-1289-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Devika Nair
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, 1161 21st Avenue South, Medical Center North S-3223, Nashville, TN, 37232-2372, USA.
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Koratala A, Segal MS, Kazory A. Integrating Point-of-Care Ultrasonography Into Nephrology Fellowship Training: A Model Curriculum. Am J Kidney Dis 2019; 74:1-5. [PMID: 30910369 DOI: 10.1053/j.ajkd.2019.02.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 02/11/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Abhilash Koratala
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, FL.
| | - Mark S Segal
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, FL
| | - Amir Kazory
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, FL
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Jaar BG, Choi MJ. An Introduction to dialysis education: Issues, innovations and impact. Semin Dial 2018; 31:99-101. [PMID: 29509328 DOI: 10.1111/sdi.12680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Bernard G Jaar
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Nephrology Center of Maryland, Baltimore, MD, USA
| | - Michael J Choi
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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