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Background: Understanding the pathophysiology of fluid distribution in acute high-risk abdominal (AHA) surgery is essential in optimizing fluid management. There is currently no data on the time course and haemodynamic implications of fluid distribution in the perioperative period and the differences between the surgical pathologies. Methods: Seventy-three patients undergoing surgery for intestinal obstruction, perforated viscus, and anastomotic leakage within a well-defined perioperative regime, including intraoperative goal-directed therapy, were included in this prospective, observational study. From 0 to 120 h, we measured body fluid volumes and hydration status by bioimpedance spectroscopy (BIA), fluid balance (input vs. output), preload dependency defined as a > 10% increase in stroke volume after preoperative fluid challenge, and post-operatively evaluated by passive leg raise. Results: We observed a progressive increase in fluid balance and extracellular volume throughout the study, irrespective of surgical diagnosis. BIA measured variables indicated post-operative overhydration in 36% of the patients, increasing to 50% on the 5th post-operative day, coinciding with a progressive increase of preload dependency, from 12% immediately post-operatively to 58% on the 5th post-operative day and irrespective of surgical diagnosis. Patients with overhydration were less haemodynamically stable than those with normo- or dehydration. Conclusion: Despite increased fluid balance and extracellular volumes, preload dependency increased progressively during the post-operative period. Our observations indicate a post-operative physiological incoherence between changes in the extracellular volume compartment and inadequate physiological preload control in patients undergoing AHA surgery. Considering the increasing overhydration during the observational period, our findings show that an indiscriminate correction of preload dependency with intravenous fluid bolus could le

Background: Understanding the pathophysiology of fluid distribution in acute high-risk abdominal (AHA) surgery is essential in optimizing fluid management. There is currently no data on the time course and haemodynamic implications of fluid distribution in the perioperative period and the differences between the surgical pathologies. Methods: Seventy-three patients undergoing surgery for intestinal obstruction, perforated viscus, and anastomotic leakage within a well-defined perioperative regime, including intraoperative goal-directed therapy, were included in this prospective, observational study. From 0 to 120 h, we measured body fluid volumes and hydration status by bioimpedance spectroscopy (BIA), fluid balance (input vs. output), preload dependency defined as a > 10% increase in stroke volume after preoperative fluid challenge, and post-operatively evaluated by passive leg raise. Results: We observed a progressive increase in fluid balance and extracellular volume throughout the study, irrespective of surgical diagnosis. BIA measured variables indicated post-operative overhydration in 36% of the patients, increasing to 50% on the 5th post-operative day, coinciding with a progressive increase of preload dependency, from 12% immediately post-operatively to 58% on the 5th post-operative day and irrespective of surgical diagnosis. Patients with overhydration were less haemodynamically stable than those with normo- or dehydration. Conclusion: Despite increased fluid balance and extracellular volumes, preload dependency increased progressively during the post-operative period. Our observations indicate a post-operative physiological incoherence between changes in the extracellular volume compartment and inadequate physiological preload control in patients undergoing AHA surgery. Considering the increasing overhydration during the observational period, our findings show that an indiscriminate correction of preload dependency with intravenous fluid bolus could le

Background About a third of patients undergoing haemodialysis have poorly controlled fluid status, which may affectsurvival. Clinical assessment is subjective and imprecise, which has led to the increasing use of devices based on bioimpedancespectroscopy (BIS). However, BIS cannot provide a simple target applicable to all patients. Our aim was to developand validate a decision aid combining clinical assessment of fluid status with information from BIS in target weightdetermination. Methods The decision aid was based on empirical experience and a literature review identifying physiological parametersalready used in the clinical assessment of fluid status. Content validity was established by patient representatives, interdisciplinarystakeholders and external experts, who assessed item relevance and comprehensiveness. Reliability was assessedby inter‐rater agreement analysis between nurses assessing typical patient cases. Results The decision aid for Recognition and Correction of Volume Alterations (RECOVA) consists of three parts (1) a scoringsystem; (2) thresholds and triggers; (3) a decision aid algorithm. Agreement between raters in the assessment of symptomswas almost perfect, with Intraclass Correlation Coefficient > 0.90. Agreement in clinical response was only fair, but increasedto moderate, with training and self‐reported confidence. Conclusion RECOVA may enable systematic clinical assessment of fluid status, facilitating early recognition of fluid alterations,and incorporation of bioimpedance into target weight management. However, implementation into clinicalpractice will require training of staff. Clinical intervention studies are required to evaluate if RECOVA facilitates response toand correction of recognised fluid alterations.

Background About a third of patients undergoing haemodialysis have poorly controlled fluid status, which may affectsurvival. Clinical assessment is subjective and imprecise, which has led to the increasing use of devices based on bioimpedancespectroscopy (BIS). However, BIS cannot provide a simple target applicable to all patients. Our aim was to developand validate a decision aid combining clinical assessment of fluid status with information from BIS in target weightdetermination. Methods The decision aid was based on empirical experience and a literature review identifying physiological parametersalready used in the clinical assessment of fluid status. Content validity was established by patient representatives, interdisciplinarystakeholders and external experts, who assessed item relevance and comprehensiveness. Reliability was assessedby inter‐rater agreement analysis between nurses assessing typical patient cases. Results The decision aid for Recognition and Correction of Volume Alterations (RECOVA) consists of three parts (1) a scoringsystem; (2) thresholds and triggers; (3) a decision aid algorithm. Agreement between raters in the assessment of symptomswas almost perfect, with Intraclass Correlation Coefficient > 0.90. Agreement in clinical response was only fair, but increasedto moderate, with training and self‐reported confidence. Conclusion RECOVA may enable systematic clinical assessment of fluid status, facilitating early recognition of fluid alterations,and incorporation of bioimpedance into target weight management. However, implementation into clinicalpractice will require training of staff. Clinical intervention studies are required to evaluate if RECOVA facilitates response toand correction of recognised fluid alterations.

Background About a third of patients undergoing haemodialysis have poorly controlled fluid status, which may affectsurvival. Clinical assessment is subjective and imprecise, which has led to the increasing use of devices based on bioimpedancespectroscopy (BIS). However, BIS cannot provide a simple target applicable to all patients. Our aim was to developand validate a decision aid combining clinical assessment of fluid status with information from BIS in target weightdetermination. Methods The decision aid was based on empirical experience and a literature review identifying physiological parametersalready used in the clinical assessment of fluid status. Content validity was established by patient representatives, interdisciplinarystakeholders and external experts, who assessed item relevance and comprehensiveness. Reliability was assessedby inter‐rater agreement analysis between nurses assessing typical patient cases. Results The decision aid for Recognition and Correction of Volume Alterations (RECOVA) consists of three parts (1) a scoringsystem; (2) thresholds and triggers; (3) a decision aid algorithm. Agreement between raters in the assessment of symptomswas almost perfect, with Intraclass Correlation Coefficient > 0.90. Agreement in clinical response was only fair, but increasedto moderate, with training and self‐reported confidence. Conclusion RECOVA may enable systematic clinical assessment of fluid status, facilitating early recognition of fluid alterations,and incorporation of bioimpedance into target weight management. However, implementation into clinicalpractice will require training of staff. Clinical intervention studies are required to evaluate if RECOVA facilitates response toand correction of recognised fluid alterations.

Background About a third of patients undergoing haemodialysis have poorly controlled fluid status, which may affectsurvival. Clinical assessment is subjective and imprecise, which has led to the increasing use of devices based on bioimpedancespectroscopy (BIS). However, BIS cannot provide a simple target applicable to all patients. Our aim was to developand validate a decision aid combining clinical assessment of fluid status with information from BIS in target weightdetermination. Methods The decision aid was based on empirical experience and a literature review identifying physiological parametersalready used in the clinical assessment of fluid status. Content validity was established by patient representatives, interdisciplinarystakeholders and external experts, who assessed item relevance and comprehensiveness. Reliability was assessedby inter‐rater agreement analysis between nurses assessing typical patient cases. Results The decision aid for Recognition and Correction of Volume Alterations (RECOVA) consists of three parts (1) a scoringsystem; (2) thresholds and triggers; (3) a decision aid algorithm. Agreement between raters in the assessment of symptomswas almost perfect, with Intraclass Correlation Coefficient > 0.90. Agreement in clinical response was only fair, but increasedto moderate, with training and self‐reported confidence. Conclusion RECOVA may enable systematic clinical assessment of fluid status, facilitating early recognition of fluid alterations,and incorporation of bioimpedance into target weight management. However, implementation into clinicalpractice will require training of staff. Clinical intervention studies are required to evaluate if RECOVA facilitates response toand correction of recognised fluid alterations.

BACKGROUND: About a third of patients undergoing haemodialysis have poorly controlled fluid status, which may affect survival. Clinical assessment is subjective and imprecise, which has led to the increasing use of devices based on bioimpedance spectroscopy (BIS). However, BIS cannot provide a simple target applicable to all patients. Our aim was to develop and validate a decision aid combining clinical assessment of fluid status with information from BIS in target weight determination. METHODS: The decision aid was based on empirical experience and a literature review identifying physiological parameters already used in the clinical assessment of fluid status. Content validity was established by patient representatives, interdisciplinary stakeholders and external experts, who assessed item relevance and comprehensiveness. Reliability was assessed by inter-rater agreement analysis between nurses assessing typical patient cases. RESULTS: The decision aid for Recognition and Correction of Volume Alterations (RECOVA) consists of three parts (1) a scoring system; (2) thresholds and triggers; (3) a decision aid algorithm. Agreement between raters in the assessment of symptoms was almost perfect, with Intraclass Correlation Coefficient > 0.90. Agreement in clinical response was only fair, but increased to moderate, with training and self-reported confidence. CONCLUSION: RECOVA may enable systematic clinical assessment of fluid status, facilitating early recognition of fluid alterations, and incorporation of bioimpedance into target weight management. However, implementation into clinical practice will require training of staff. Clinical intervention studies are required to evaluate if RECOVA facilitates response to and correction of recognised fluid alterations.

Background About a third of patients undergoing haemodialysis have poorly controlled fluid status, which may affectsurvival. Clinical assessment is subjective and imprecise, which has led to the increasing use of devices based on bioimpedancespectroscopy (BIS). However, BIS cannot provide a simple target applicable to all patients. Our aim was to developand validate a decision aid combining clinical assessment of fluid status with information from BIS in target weightdetermination. Methods The decision aid was based on empirical experience and a literature review identifying physiological parametersalready used in the clinical assessment of fluid status. Content validity was established by patient representatives, interdisciplinarystakeholders and external experts, who assessed item relevance and comprehensiveness. Reliability was assessedby inter‐rater agreement analysis between nurses assessing typical patient cases. Results The decision aid for Recognition and Correction of Volume Alterations (RECOVA) consists of three parts (1) a scoringsystem; (2) thresholds and triggers; (3) a decision aid algorithm. Agreement between raters in the assessment of symptomswas almost perfect, with Intraclass Correlation Coefficient > 0.90. Agreement in clinical response was only fair, but increasedto moderate, with training and self‐reported confidence. Conclusion RECOVA may enable systematic clinical assessment of fluid status, facilitating early recognition of fluid alterations,and incorporation of bioimpedance into target weight management. However, implementation into clinicalpractice will require training of staff. Clinical intervention studies are required to evaluate if RECOVA facilitates response toand correction of recognised fluid alterations.

[Abstract] Background: Overhydration (OH) complicates frequently the clinical course of Peritoneal Dialysis (PD) patients, and keeps a controversial association with the risk of peritoneal infection. The main objective of this study was to disclose an association between persistent OH and the risk of enteric peritonitis in a relatively large sample of patients undergoing PD. Method: Following a prospective design, we monitorized systematically body composition of patients treated with PD in our unit (2011–2016), searching for a correlation with the ensuing risk of peritonitis, with an emphasis on the association between persistent OH (main study variable) and the risk of infection by enteric pathogens (main outcome). Essential demographic, clinical and laboratory variables with a potential influence on the risk of peritonitis were recorded. We used multivariate survival analysis to clarify the specific effect of different body composition parameters on the main outcome. Main results: We included 139 patients for analysis (mean follow-up 24 months). Sixty-three patients suffered at least one peritonitis, and 17 had at least one diagnosis of enteric peritonitis. Univariate analysis disclosed a general trend to an increased risk of enteric peritonitis in overhydrated patients, as evidenced by associations of this outcome with mean extracellular water/intracellular water (ECW/ICW)(p = 0007), OH/ECW (p = 0033) and ECW/total body water (ECW/TBW)(p = 0004) ratios, but not with absolute OH values. Multivariate analysis confirmed similar associations or trends (RR 3,48, 95 % CI 1,03–14,59, p = 0,046, highest versus lowest tertile of ECW/ICW, RR 2,31, 95 % CI 0,98-6,56, p = 0,061, highest versus lowest tertile of OH/ECW, and RR 6,33, 95 % CI 1,37-19,37, p = 0,011, highest versus lowest tertile of ECW/TBW). On the contrary, no apparent association was detected between OH and the overall risk of peritoneal infection., [Resumen] Antecedentes y objetivos. La sobrehidratación (SH) es frecuente, y a menudo persistente, en pacientes tratados con diálisis peritoneal (DP), y mantiene una asociación controvertida con el riesgo de infección peritoneal. El objetivo principal de este estudio fue desvelar una posible asociación entre la presencia de SH y el riesgo subsiguiente de infección peritoneal por gérmenes entéricos, en una población relativamente amplia de pacientes tratados con DP. Método Según diseño prospectivo, monitorizamos de manera sistemática la composición corporal de pacientes tratados con DP en nuestra unidad (2011-2016), buscando una posible correlación con el riesgo de peritonitis durante el seguimiento, con un interés particular en la asociación entre SH persistente (variable de estudio principal) y el riesgo de infección peritoneal por patógenos entéricos (variable resultado principal). Para el análisis tuvimos en cuenta variables demográficas, clínicas y de laboratorio con influencia potencial en el riesgo de infección peritoneal. Utilizamos técnicas de análisis multivariante para clarificar el efecto específico de diferentes parámetros de composición corporal sobre la variable resultado principal. Resultados principales. Incluimos 139 pacientes, con seguimiento medio de 24 meses. Sesenta y tres pacientes sufrieron al menos una peritonitis, y 17 al menos una infección por gérmenes entéricos. El análisis univariante mostró una tendencia general a mayor riesgo de infección peritoneal entérica en pacientes sobrehidratados, que se hacía evidente cuando se usaba el cociente agua extracelular/agua intracelular (AEC/AIC) (p=0,007), el cociente SH/AEC (SH/AEG) (p=0,033), o el cociente AEC/agua corporal total (AEC/ACT) (p=0,004), pero no cuando se usaba la SH absoluta, como variable de estudio. El análisis multivariante confirmó estas asociaciones o tendencias (RR: 3,48; IC 95%: 1,03-14,59; p=0,046, tercil mayor versus menor para AEC/AIC, RR: 2,31; IC 95%: 0,98-6,56; p=0,061

Aims and objectives To measure the prevalence of symptomatic (S‐IDH) and asymptomatic intradialytic hypotension (A‐IDH) or postdialysis overhydration in a satellite haemodialysis clinic in Western Australia. Background Intradialytic hypotension is one of the most common side effects of haemodialysis caused by ultrafiltration provoking a temporary volume depletion. The prevalence of asymptomatic hypotension during dialysis has been rarely reported, but is considered to have the same negative consequences as symptomatic hypotension on various end organs like the brain and the gastrointestinal tract. Design Observational study on a retrospective 3‐month period of nursing recorded fluid‐related adverse events. Methods Data collection on the occurrence of S‐IDH and A‐IDH during a total of 2,357 haemodialysis treatments in 64 patients. Body weight of patients at the time of cessation of treatment was recorded, and patients, whose weight exceeded their ideal body weight by at least 0.5 kg, were classified as overhydrated. Data analysis was performed using spss version 24 software. Results Symptomatic intradialytic hypotension was the most common adverse event measured in this cohort, and occurred during 221 (9.4%) of all treatments, whereas asymptomatic intradialytic hypotension occurred in 88 (3.7%) of all treatments. The total occurrence of intradialytic hypotension was 13.1%, and symptomatic was observed in 30 patients, implying that nearly every second patient had at least one symptomatic episode within 3 months. Overhydration occurred in a total of 103 (4.4%) of all treatments, and involved 17 patients. Conclusions Symptomatic and asymptomatic intradialytic hypotension were the most commonly observed adverse events in this cohort; overhydration occurrence was considerably less common. Relevance to clinical practice The high occurrence of hypotension‐related events demonstrates that ultrafiltration treatment goals in satellite dialysis clinics are sometimes overestimat

Aims and objectives To measure the prevalence of symptomatic (S‐IDH) and asymptomatic intradialytic hypotension (A‐IDH) or postdialysis overhydration in a satellite haemodialysis clinic in Western Australia. Background Intradialytic hypotension is one of the most common side effects of haemodialysis caused by ultrafiltration provoking a temporary volume depletion. The prevalence of asymptomatic hypotension during dialysis has been rarely reported, but is considered to have the same negative consequences as symptomatic hypotension on various end organs like the brain and the gastrointestinal tract. Design Observational study on a retrospective 3‐month period of nursing recorded fluid‐related adverse events. Methods Data collection on the occurrence of S‐IDH and A‐IDH during a total of 2,357 haemodialysis treatments in 64 patients. Body weight of patients at the time of cessation of treatment was recorded, and patients, whose weight exceeded their ideal body weight by at least 0.5 kg, were classified as overhydrated. Data analysis was performed using spss version 24 software. Results Symptomatic intradialytic hypotension was the most common adverse event measured in this cohort, and occurred during 221 (9.4%) of all treatments, whereas asymptomatic intradialytic hypotension occurred in 88 (3.7%) of all treatments. The total occurrence of intradialytic hypotension was 13.1%, and symptomatic was observed in 30 patients, implying that nearly every second patient had at least one symptomatic episode within 3 months. Overhydration occurred in a total of 103 (4.4%) of all treatments, and involved 17 patients. Conclusions Symptomatic and asymptomatic intradialytic hypotension were the most commonly observed adverse events in this cohort; overhydration occurrence was considerably less common. Relevance to clinical practice The high occurrence of hypotension‐related events demonstrates that ultrafiltration treatment goals in satellite dialysis clinics are sometimes overestimat

Title: Ultrasound measurements on the inferior vena cava (IVC-US) by renal nursing staff for assessment and management of intravascular volume status in haemodialysis patients. Aims: The primary aim of this thesis was to provide evidence that renal nurses could safely and efficiently perform IVC-US on haemodialysis patients to obtain objective assessment of intravascular volume status and potentially reduce adverse events and morbidity. The secondary aims for this study were: (1) conduct a systematic literature review to identify evidence if renal nurses have previously used this method for intravascular volume assessment; (2) teach a renal nurse through a staged educational programme, guided by a medically trained ultrasonographer, a sonologist, to gain competency in ultrasound image acquisition and interpretation of the scans; (3) measure the prevalence of any form of intradialytic hypotension in a satellite haemodialysis clinic over a three-month period and (4) attain concurrent IVC-US and bioimpedance spectroscopy measurements on 30 patients during their haemodialysis treatment and to compare these findings with their intravascular volume status using the traditional clinical nursing assessment method. Materials and Methods: To achieve this primary aim, this thesis was separated into multiple phases. First, a systematic literature review of medical and nursing databases was performed to summarise the use of IVC-US in haemodialysis patients by renal nurses. The second phase involved a retrospective data analysis, where the prevalence rate of nurse-documented fluid related intradialytic hypotensive events was measured and a Generalised Estimating Equation (GEE) model was used to predict the likelihood of any form of intradialytic hypotension or postdialytic overhydration. In the next phase a four-step educational programme was developed in collaboration with an expert sonologist, guiding the renal nurse through the process of skill acquisition and accurate fluid a

[Abstract] Background: Volume overload is frequent in diabetics undergoing peritoneal dialysis (PD), and may play a significant role in the excess mortality observed in these patients. The characteristics of peritoneal water transport in this population have not been studied sufficiently. Method: Following a prospective, single-center design we made cross-sectional and longitudinal comparisons of peritoneal water transport in 2 relatively large samples of diabetic and nondiabetic PD patients. We used 3.86/4.25% glucose-based peritoneal equilibration tests (PET) with complete drainage at 60 min, for these purposes. Main Results: We scrutinized 59 diabetic and 120 nondiabetic PD patients. Both samples showed relatively similar characteristics, although diabetics were significantly more overhydrated than nondiabetics. The baseline PET disclosed lower ultrafiltration (mean 439 mL diabetics vs. 532 mL nondiabetics, p = 0.033) and sodium removal (41 vs. 53 mM, p = 0.014) rates in diabetics. One hundred and nine patients (36 diabetics) underwent a second PET after 12 months, and 45 (14 diabetics) underwent a third one after 24 months. Longitudinal analyses disclosed an essential stability of water transport in both groups, although nondiabetic patients showed a trend where an increase in free water transport (p = 0.033) was observed, which was not the case in diabetics. Conclusions: Diabetic patients undergoing PD present lower capacities of ultrafiltration and sodium removal than their nondiabetic counterparts. Longitudinal analyses disclose an essential stability of water transport capacities, both in diabetics and nondiabetics. The clinical significance of these differences deserves further analysis.

This is an author's manuscript of: Steinwandel, U., Gibson, N., Towell‐Barnard, M., Parsons, R., Rippey, J. J. R., & Rosman, J. (2018). Measuring the prevalence of intradialytic hypotension in a satellite dialysis clinic: Are we too complacent?. Journal of Clinical Nursing, 27, e1561-e1570. doi:10.1111/jocn.14309 Available here.