Introduction: Saprophytic growth of Aspergillus species in preexisting lung cavities commonly presents with hemoptysis. Surgical resection is the preferred treatment for hemoptysis control in pulmonary aspergilloma. In patients, who are not candidates for surgical resection bronchoscopic Voriconazole instillation, is an effective option.Materials and Methods: In this retrospective study, data of patients presenting with active hemoptysis, radiological evidence of aspergilloma and those undergoing bronchoscopic Voriconazole instillation at National Academy of Medical Sciences from January 2018 to December 2018 were retrieved. Clinical details including the severity of hemoptysis, number, size and location of aspergilloma, number of Voriconazole instillation sessions and symptom control were assessed. Follow up CT scan after four to six sessions were also evaluated to compare the size of aspergilloma.Results: A total of 11 patients presented with aspergilloma and hemoptysis. Of these, five (45.4%) patients underwent at least four sessions of bronchoscopic Voriconazole instillation. Two patients required six sessions whereas one required nine sessions for hemoptysis control. The procedure was successful in all patients; however, one had a recurrence after 3 months and required bronchial artery embolisation. In four patients there was a reduction in the size of aspergilloma on follow up CT scan. The procedure was well tolerated by all the patients, except for a mild increase in cough in the immediate post-procedure period.Conclusions: Intrabronchial Voriconazole instillation is a safe and effective option for hemoptysis control in patients with pulmonary aspergilloma. However, the optimal dose, frequency, and duration of Voriconazole instillation need to be further evaluated.
{"title":"Bronchoscopic Voriconazole Instillation in Pulmonary Aspergilloma: A Single Center Experience","authors":"P. Shrestha, A. Dhungana","doi":"10.3126/NMJ.V2I1.24495","DOIUrl":"https://doi.org/10.3126/NMJ.V2I1.24495","url":null,"abstract":"Introduction: Saprophytic growth of Aspergillus species in preexisting lung cavities commonly presents with hemoptysis. Surgical resection is the preferred treatment for hemoptysis control in pulmonary aspergilloma. In patients, who are not candidates for surgical resection bronchoscopic Voriconazole instillation, is an effective option.Materials and Methods: In this retrospective study, data of patients presenting with active hemoptysis, radiological evidence of aspergilloma and those undergoing bronchoscopic Voriconazole instillation at National Academy of Medical Sciences from January 2018 to December 2018 were retrieved. Clinical details including the severity of hemoptysis, number, size and location of aspergilloma, number of Voriconazole instillation sessions and symptom control were assessed. Follow up CT scan after four to six sessions were also evaluated to compare the size of aspergilloma.Results: A total of 11 patients presented with aspergilloma and hemoptysis. Of these, five (45.4%) patients underwent at least four sessions of bronchoscopic Voriconazole instillation. Two patients required six sessions whereas one required nine sessions for hemoptysis control. The procedure was successful in all patients; however, one had a recurrence after 3 months and required bronchial artery embolisation. In four patients there was a reduction in the size of aspergilloma on follow up CT scan. The procedure was well tolerated by all the patients, except for a mild increase in cough in the immediate post-procedure period.Conclusions: Intrabronchial Voriconazole instillation is a safe and effective option for hemoptysis control in patients with pulmonary aspergilloma. However, the optimal dose, frequency, and duration of Voriconazole instillation need to be further evaluated.","PeriodicalId":52856,"journal":{"name":"Nepalese Medical Journal","volume":"22 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85307019","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction: Intraurethral instillation of 2% lignocaine hydrochloride is associated with discomfort and stinging sensation, especially to male patients. This study was aimed to determine whether slow instillation and cooled gel reduce this discomfort.Materials and Methods: A prospective randomized study was done comparing initial and procedural discomfort between 2% lignocaine instilled at room temperature and cooled to 4° C, and that instilled over 2 seconds and 10 seconds. Hundred and sixty male patients were divided into two groups of eighty each for the two studies.Results: Significant reduction in initial discomfort was observed with 10ml of 2% lignocaine hydrochloride cooled to 4° C and also when instilled over 10 seconds. Although procedural discomfort was also lesser in these two sets, it was not statistically significant.Conclusions: Discomfort, the most common complaint of male patients during rigid cystoscopy, can be reduced by slow instillation of lignocaine hydrochloride gel and also if the gel is cooled to 4° C.
{"title":"Slow Instillation of Cooled Lignocaine Gel: Does it Reduce Urethral Discomfort During Cystoscopy?","authors":"R. B. Basnet, A. Shah, C. Shah","doi":"10.3126/NMJ.V2I1.23703","DOIUrl":"https://doi.org/10.3126/NMJ.V2I1.23703","url":null,"abstract":"Introduction: Intraurethral instillation of 2% lignocaine hydrochloride is associated with discomfort and stinging sensation, especially to male patients. This study was aimed to determine whether slow instillation and cooled gel reduce this discomfort.Materials and Methods: A prospective randomized study was done comparing initial and procedural discomfort between 2% lignocaine instilled at room temperature and cooled to 4° C, and that instilled over 2 seconds and 10 seconds. Hundred and sixty male patients were divided into two groups of eighty each for the two studies.Results: Significant reduction in initial discomfort was observed with 10ml of 2% lignocaine hydrochloride cooled to 4° C and also when instilled over 10 seconds. Although procedural discomfort was also lesser in these two sets, it was not statistically significant.Conclusions: Discomfort, the most common complaint of male patients during rigid cystoscopy, can be reduced by slow instillation of lignocaine hydrochloride gel and also if the gel is cooled to 4° C.","PeriodicalId":52856,"journal":{"name":"Nepalese Medical Journal","volume":"45 1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90041650","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Blood stream infections and sepsis are major causes of hospitalization in most intensive care units around the globe, especially in developing countries like Nepal. Although the sepsis guidelines emphasize the role of early institution of appropriate antibiotics, it is practically challenging due to delayed turnover time of currently available diagnostic tests. Modifications in traditional blood culture methods, use of molecular techniques and availability of biomarkers have raised hope in rapid detection of blood stream infections.
{"title":"Rapid Diagnosis of Blood Stream Infections in ICU: Recent Advances","authors":"R. Pangeni","doi":"10.3126/NMJ.V2I1.23980","DOIUrl":"https://doi.org/10.3126/NMJ.V2I1.23980","url":null,"abstract":"Blood stream infections and sepsis are major causes of hospitalization in most intensive care units around the globe, especially in developing countries like Nepal. Although the sepsis guidelines emphasize the role of early institution of appropriate antibiotics, it is practically challenging due to delayed turnover time of currently available diagnostic tests. Modifications in traditional blood culture methods, use of molecular techniques and availability of biomarkers have raised hope in rapid detection of blood stream infections.","PeriodicalId":52856,"journal":{"name":"Nepalese Medical Journal","volume":"104 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76117285","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Naqvi, S. I. Ali, V. Parmar, C. Oh, S. Beardmore, N. Subedi
Radiologists frequently interpret cross-sectional imaging of the spine in the setting of trauma. Mechanical stability of the traumatised spine is the single most important factor which guides further management. Several classification systems have been developed over the past to assist radiologists to judge the potentially unstable injuries. The radiologists are arguably most familiar with Denis system of classification which is based on injury morphology and mechanism. This system has been criticised for being too simple, not prognostically valuable and lack of consideration of patients' neurological status. AO (Arbeitsgemeinschaft für Osteosynthesefragen) and TLICS (Thoracolumbar Injury Classification and Severity Score ) classification systems are the next major evolutions which highlight the importance of the posterior ligamentous complex (PLC) and neurological status of the patients in predicting the potentially unstable fracture. The aim of this pictorial review is to familiarise radiologists with newer classification systems to improve their image interpretation skills and promote efficient communication with spinal surgeons. The pictorial examples are intended to illustrate the various injury types and how to classify them according to the aforementioned classification systems.
放射科医生经常在创伤的情况下解释脊柱的横断成像。损伤脊柱的机械稳定性是指导进一步治疗的最重要因素。过去已经开发了几种分类系统，以帮助放射科医生判断潜在的不稳定损伤。放射科医生最熟悉的是基于损伤形态和机制的丹尼斯分类系统。该系统被批评过于简单，没有预后价值，缺乏对患者神经系统状态的考虑。AO (Arbeitsgemeinschaft f r osteosynthesis efragen)和TLICS(胸腰椎损伤分类和严重程度评分)分类系统是下一个主要的进化，它们强调了后韧带复合体(PLC)和患者神经系统状态在预测潜在不稳定骨折中的重要性。这篇图片综述的目的是让放射科医生熟悉新的分类系统，以提高他们的图像解释技能，并促进与脊柱外科医生的有效沟通。图像示例旨在说明各种伤害类型以及如何根据上述分类系统对其进行分类。
{"title":"Comprehensive Radiological Assessment of Sub-axial Spinal Injury","authors":"J. Naqvi, S. I. Ali, V. Parmar, C. Oh, S. Beardmore, N. Subedi","doi":"10.3126/NMJ.V2I1.24351","DOIUrl":"https://doi.org/10.3126/NMJ.V2I1.24351","url":null,"abstract":"Radiologists frequently interpret cross-sectional imaging of the spine in the setting of trauma. Mechanical stability of the traumatised spine is the single most important factor which guides further management. \u0000Several classification systems have been developed over the past to assist radiologists to judge the potentially unstable injuries. The radiologists are arguably most familiar with Denis system of classification which is based on injury morphology and mechanism. This system has been criticised for being too simple, not prognostically valuable and lack of consideration of patients' neurological status. AO (Arbeitsgemeinschaft für Osteosynthesefragen) and TLICS (Thoracolumbar Injury Classification and Severity Score ) classification systems are the next major evolutions which highlight the importance of the posterior ligamentous complex (PLC) and neurological status of the patients in predicting the potentially unstable fracture. \u0000The aim of this pictorial review is to familiarise radiologists with newer classification systems to improve their image interpretation skills and promote efficient communication with spinal surgeons. The pictorial examples are intended to illustrate the various injury types and how to classify them according to the aforementioned classification systems.","PeriodicalId":52856,"journal":{"name":"Nepalese Medical Journal","volume":"12 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89288448","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
N. Mainali, N. Nepal, P. K. Choudhary, Agraj Uprety
Tubercular lymphadenitis is one of the most common extrapulmonary tubercular lesions presented in the Outpatient Department which is commonly diagnosed by Fine needle aspiration cytology. Cytological diagnosis of tuberculosis requires the presence of epithelioid cell granulomas demonstration with or without Langhan’s giant cells and necrosis. Sometimes, there can a proliferation of signet like cells without granulomas, which in a cervical lymph node can be given a false interpretation of metastatic signet cell carcinoma. A 35 year female patient with a complaint of cervical lymphadenopathy came to the medical OPD. FNAC was done which showed numerous scattered signet ring cells. However, epithelioid cell granulomas weren’t observed in the smears. Zeihl Neelsen stain for Acid fast bacilli was done but the organism wasn’t appreciated. A biopsy was done and a histopathological slide showed epithelioid cell granulomas and Langhan’s giant cell. Zeihl Neelsen Stain for Acid fast bacilli, which was positive.
{"title":"Tubercular Lymphadenitis Mimicking Findings of Metastatic Signet Cell Carcinoma in FNAC: A Case Report","authors":"N. Mainali, N. Nepal, P. K. Choudhary, Agraj Uprety","doi":"10.3126/NMJ.V2I1.24505","DOIUrl":"https://doi.org/10.3126/NMJ.V2I1.24505","url":null,"abstract":"Tubercular lymphadenitis is one of the most common extrapulmonary tubercular lesions presented in the Outpatient Department which is commonly diagnosed by Fine needle aspiration cytology. Cytological diagnosis of tuberculosis requires the presence of epithelioid cell granulomas demonstration with or without Langhan’s giant cells and necrosis. Sometimes, there can a proliferation of signet like cells without granulomas, which in a cervical lymph node can be given a false interpretation of metastatic signet cell carcinoma. \u0000A 35 year female patient with a complaint of cervical lymphadenopathy came to the medical OPD. FNAC was done which showed numerous scattered signet ring cells. However, epithelioid cell granulomas weren’t observed in the smears. Zeihl Neelsen stain for Acid fast bacilli was done but the organism wasn’t appreciated. A biopsy was done and a histopathological slide showed epithelioid cell granulomas and Langhan’s giant cell. Zeihl Neelsen Stain for Acid fast bacilli, which was positive.","PeriodicalId":52856,"journal":{"name":"Nepalese Medical Journal","volume":"17 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84582716","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Vitamin B12 deficiency usually presents with megaloblastic anemia, pancytopenia, and neurological symptoms. The cause is usually, nutritional deficiency, increase demand, decrease absorption. This report describes a case with symptoms of apathy and findings suggestive of severe hemolytic anemia, diagnosed with vitamin B12 deficiency. Haemolysis is a rare hematological finding in cases of B12 deficiency, and descriptions of a nutritional vitamin B12 deficiency, without evidence of pernicious anaemia, causing haemolysis, are even scarcer, and this paper was intended to draw physicians’ attention to this rare form of presentation.
{"title":"Severe Haemolytic Anaemia, a Rare Presentation of Nutritional Vitamin B12 Deficiency: A Case Report","authors":"A. Siddiqui","doi":"10.3126/NMJ.V2I1.24556","DOIUrl":"https://doi.org/10.3126/NMJ.V2I1.24556","url":null,"abstract":"Vitamin B12 deficiency usually presents with megaloblastic anemia, pancytopenia, and neurological symptoms. The cause is usually, nutritional deficiency, increase demand, decrease absorption. This report describes a case with symptoms of apathy and findings suggestive of severe hemolytic anemia, diagnosed with vitamin B12 deficiency. Haemolysis is a rare hematological finding in cases of B12 deficiency, and descriptions of a nutritional vitamin B12 deficiency, without evidence of pernicious anaemia, causing haemolysis, are even scarcer, and this paper was intended to draw physicians’ attention to this rare form of presentation.","PeriodicalId":52856,"journal":{"name":"Nepalese Medical Journal","volume":"343 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-05-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75461260","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Diabetes mellitus is a global health problem in 21st century. The incidence of diabetes mellitus is in rise and is estimated to be more prevalent in coming years. It is becoming one of the most common non-infectious and non-neoplastic causes of morbidity and mortality. Various complications are associated with diabetes mellitus. With control of blood glucose level, complications of diabetes mellitus can be minimized. In different time frame, different parameters and level have been used to diagnose diabetes. Glycosylated hemoglobin A1c is one of the reliable indicator of chronic hyperglycemia. In 2011, World Health Organization has included HbA1c in the diagnostic criteria. Various methods are used to detect the level of HbA1c. Glycosylated hemoglobin is being used in the management of diabetes mellitus. Various studies have shown its prognostic implication in micro and macrovascular complications. Here we discuss various methods of estimation of HbA1c, various role of HbA1c in the management of Diabetes Mellitus and limitation of the test.
{"title":"Diabetes Mellitus And Glycosylated Hemoglobin A1c","authors":"S. Kc","doi":"10.3126/NMJ.V1I2.21744","DOIUrl":"https://doi.org/10.3126/NMJ.V1I2.21744","url":null,"abstract":"Diabetes mellitus is a global health problem in 21st century. The incidence of diabetes mellitus is in rise and is estimated to be more prevalent in coming years. It is becoming one of the most common non-infectious and non-neoplastic causes of morbidity and mortality. Various complications are associated with diabetes mellitus. With control of blood glucose level, complications of diabetes mellitus can be minimized. In different time frame, different parameters and level have been used to diagnose diabetes. Glycosylated hemoglobin A1c is one of the reliable indicator of chronic hyperglycemia. In 2011, World Health Organization has included HbA1c in the diagnostic criteria. Various methods are used to detect the level of HbA1c. Glycosylated hemoglobin is being used in the management of diabetes mellitus. Various studies have shown its prognostic implication in micro and macrovascular complications. Here we discuss various methods of estimation of HbA1c, various role of HbA1c in the management of Diabetes Mellitus and limitation of the test. ","PeriodicalId":52856,"journal":{"name":"Nepalese Medical Journal","volume":"137 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2018-12-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79963936","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction: The different mood states in our daily life can affect our mental and emotional health. The aim of our study was to explore photoplethysmography to record heart rate variability as a marker of changes in mood states in our daily life.Materials and Methods: Two groups of affective pictures categorized into positive and negative sets were shown to thirty subjects on two different consecutive days with simultaneously recording of heart rate variability for 5 minutes by photoplethysmography technique. Immediately after recording on each day, 0-9 self-assessment scale was used to assess the mood state of the subject after viewing the set of pictures.Results: Sympathetic domains of heart rate variability like low frequency (200.3 ±4.1 vs. 166.7 ±2.8, p<0.05), low- and high frequency ratio (1.45 ± 0.21 vs. 0.55 ± 0.07, p<0.05) and low frequency (55.8 ± 2.9 vs. 38.6 ± 2.8, p<0.05) significantly increased in negative mood state condition as compared to positive mood state condition. High frequency (157.9 ± 3.9 vs. 264.3 ± 5.3, p<0.05) and high frequency (44 ± 2.9 vs. 61.2 ±4.2, p< 0.05) significantly increased in positive mood state condition as compared to negative mood state condition. There was significant increase in heart rate (78 ± 2.99 vs. 73 ± 3.11, p<0.05) in negative mood state as compared to positive mood state.Conclusions: Increase in sympathetic activity during negative mood state and increase in parasympathetic activity during positive mood state measured by photoplethysmography technique validates this easy and noninvasive mental assessment tool to determine different mood states.
{"title":"Heart Rate Variability as a Marker of Changes in Mood State in Daily Life by Photoplethysmography Technique","authors":"S. Deo, Kopila Agrawal, Prem Bhattarai","doi":"10.3126/NMJ.V1I2.21601","DOIUrl":"https://doi.org/10.3126/NMJ.V1I2.21601","url":null,"abstract":"Introduction: The different mood states in our daily life can affect our mental and emotional health. The aim of our study was to explore photoplethysmography to record heart rate variability as a marker of changes in mood states in our daily life.Materials and Methods: Two groups of affective pictures categorized into positive and negative sets were shown to thirty subjects on two different consecutive days with simultaneously recording of heart rate variability for 5 minutes by photoplethysmography technique. Immediately after recording on each day, 0-9 self-assessment scale was used to assess the mood state of the subject after viewing the set of pictures.Results: Sympathetic domains of heart rate variability like low frequency (200.3 ±4.1 vs. 166.7 ±2.8, p<0.05), low- and high frequency ratio (1.45 ± 0.21 vs. 0.55 ± 0.07, p<0.05) and low frequency (55.8 ± 2.9 vs. 38.6 ± 2.8, p<0.05) significantly increased in negative mood state condition as compared to positive mood state condition. High frequency (157.9 ± 3.9 vs. 264.3 ± 5.3, p<0.05) and high frequency (44 ± 2.9 vs. 61.2 ±4.2, p< 0.05) significantly increased in positive mood state condition as compared to negative mood state condition. There was significant increase in heart rate (78 ± 2.99 vs. 73 ± 3.11, p<0.05) in negative mood state as compared to positive mood state.Conclusions: Increase in sympathetic activity during negative mood state and increase in parasympathetic activity during positive mood state measured by photoplethysmography technique validates this easy and noninvasive mental assessment tool to determine different mood states.","PeriodicalId":52856,"journal":{"name":"Nepalese Medical Journal","volume":"07 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2018-12-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86174314","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sanjay Shrestha, A. Ghimire, Safiur Rahman Ansari, Ashok Adhikari
Introduction: Accurate assessment of fluid status in hemodialysis patients presents a significant challenge. Nephrologists have long relied on dry weight estimation based solely on clinical parameters to decide the ultrafiltration volume for patients with end-stage kidney disease on dialysis. However, this method is far from accurate and many patients recurrently suffer from signs and symptoms of fluid overload or circulatory collapse from overaggressive ultrafiltration. Invasive methods such as measurement of central venous pressure cannot be used routinely. We evaluated the usefulness of inferior vena cava (IVC) diameter measured by handheld ultrasound in the estimation of fluid status in patients before and after hemodialysis. Materials and Methods: Clinical assessment included patients’ symptoms, weight, blood pressure, heart rate, and presence of edema before and after dialysis session. Dry weight was assessed based on the above parameters. Each patient underwent measurement of inferior vena cava before and after hemodialysis. The anteroposterior IVC diameter (IVCD) was measured 1.5 cm below the diaphragm in the hepatic segment in supine position during normal inspiration and expiration.Results: Thirty hemodialysis patients (mean age 51.6±18.03 years) were evaluated in outpatient dialysis unit. Following hemodialysis mean IVCe (IVC diameter in expiration) decreased from 1.40±0.38 to 0.91±0.30 cm (p<0.001). Similarly, mean IVCi (IVC diameter in inspiration) decreased from 0.67±0.34 to 0.35±0.19 cm (p<0.001). Changes in IVCD were significantly correlated with alterations in body weight following dialysis (p<0.0001). The IVC collapsibility index (IVC-CI, per cent of change in IVC diameter in expiration vs. inspiration) increased significantly from 0.53±0.18 to 0.68±0.18 after dialysis (p=0.002). IVC diameter and IVC-CI clearly reflected alterations in fluid status. Regarding the clinical parameters of fluid status, following hemodialysis, mean heart rate increased from 81.17±5.21 beats per minute to 86.50±7.99, (p=0.003), systolic blood pressure increased from 148.67±26.36 mmHg to 155.00±28.50, (p=0.05), and diastolic blood pressure increased from 78.62±12.74 mmHg to 84.83±14.55, (p<0.001).Conclusions: Our findings support the applicability of IVCD measurement and IVC-CI in the estimation of fluid status in end stage kidney disease patients on hemodialysis. The clinical parameters of fluid status including heart rate, systolic blood pressure, and diastolic blood pressure suggest that significant numbers of patients underwent excess ultrafiltration based on their traditional dry weight calculation. Thus, using IVC parameters before and during hemodialysis might give a better estimation of fluid status of the patient and guide the amount of ultrafiltration to be done.
简介:准确评估血液透析患者的液体状态提出了一个重大挑战。长期以来，肾病学家仅仅依靠临床参数来估计干重来决定终末期肾病透析患者的超滤体积。然而，这种方法远不准确，许多患者经常出现过度过度超滤引起的液体过载或循环衰竭的体征和症状。侵入性方法如测量中心静脉压不能常规使用。我们评估了手持式超声测量下腔静脉(IVC)直径在估计血液透析前后患者液体状态中的有用性。材料与方法:临床评估包括患者透析前后的症状、体重、血压、心率和水肿情况。根据上述参数评定干重。每位患者在血液透析前后均行下腔静脉测量。在正常吸气和呼气时，取仰卧位，在肝段膈下1.5 cm处测量肝段前后静脉内径(IVCD)。结果:对门诊透析患者30例(平均年龄51.6±18.03岁)进行了评价。血液透析后平均IVCe(呼气时IVC直径)由1.40±0.38 cm降至0.91±0.30 cm (p<0.001)。同样，平均IVCi(吸气腔内IVC直径)从0.67±0.34 cm下降到0.35±0.19 cm (p<0.001)。IVCD的改变与透析后体重的改变显著相关(p<0.0001)。透析后IVC溃散指数(IVC- ci，呼气时与吸气时IVC直径变化百分比)由0.53±0.18显著增加至0.68±0.18 (p=0.002)。下腔静脉内径和下腔静脉-内径清晰地反映了流体状态的变化。血液透析后，患者平均心率由81.17±5.21次/分上升至86.50±7.99次/分(p=0.003)，收缩压由148.67±26.36 mmHg上升至155.00±28.50 mmHg (p=0.05)，舒张压由78.62±12.74 mmHg上升至84.83±14.55 mmHg (p<0.001)。结论:我们的研究结果支持IVCD测量和IVC-CI在评估终末期肾脏疾病血液透析患者体液状态方面的适用性。包括心率、收缩压和舒张压在内的体液状态的临床参数表明，基于传统的干重计算，大量患者进行了过量的超滤。因此，在血液透析前和透析过程中使用IVC参数可以更好地估计患者的液体状态，并指导超滤的量。
{"title":"Use of Handheld Ultrasound to Estimate Fluid Status of Hemodialysis Patients","authors":"Sanjay Shrestha, A. Ghimire, Safiur Rahman Ansari, Ashok Adhikari","doi":"10.3126/NMJ.V1I2.21584","DOIUrl":"https://doi.org/10.3126/NMJ.V1I2.21584","url":null,"abstract":"Introduction: Accurate assessment of fluid status in hemodialysis patients presents a significant challenge. Nephrologists have long relied on dry weight estimation based solely on clinical parameters to decide the ultrafiltration volume for patients with end-stage kidney disease on dialysis. However, this method is far from accurate and many patients recurrently suffer from signs and symptoms of fluid overload or circulatory collapse from overaggressive ultrafiltration. Invasive methods such as measurement of central venous pressure cannot be used routinely. We evaluated the usefulness of inferior vena cava (IVC) diameter measured by handheld ultrasound in the estimation of fluid status in patients before and after hemodialysis. Materials and Methods: Clinical assessment included patients’ symptoms, weight, blood pressure, heart rate, and presence of edema before and after dialysis session. Dry weight was assessed based on the above parameters. Each patient underwent measurement of inferior vena cava before and after hemodialysis. The anteroposterior IVC diameter (IVCD) was measured 1.5 cm below the diaphragm in the hepatic segment in supine position during normal inspiration and expiration.Results: Thirty hemodialysis patients (mean age 51.6±18.03 years) were evaluated in outpatient dialysis unit. Following hemodialysis mean IVCe (IVC diameter in expiration) decreased from 1.40±0.38 to 0.91±0.30 cm (p<0.001). Similarly, mean IVCi (IVC diameter in inspiration) decreased from 0.67±0.34 to 0.35±0.19 cm (p<0.001). Changes in IVCD were significantly correlated with alterations in body weight following dialysis (p<0.0001). The IVC collapsibility index (IVC-CI, per cent of change in IVC diameter in expiration vs. inspiration) increased significantly from 0.53±0.18 to 0.68±0.18 after dialysis (p=0.002). IVC diameter and IVC-CI clearly reflected alterations in fluid status. Regarding the clinical parameters of fluid status, following hemodialysis, mean heart rate increased from 81.17±5.21 beats per minute to 86.50±7.99, (p=0.003), systolic blood pressure increased from 148.67±26.36 mmHg to 155.00±28.50, (p=0.05), and diastolic blood pressure increased from 78.62±12.74 mmHg to 84.83±14.55, (p<0.001).Conclusions: Our findings support the applicability of IVCD measurement and IVC-CI in the estimation of fluid status in end stage kidney disease patients on hemodialysis. The clinical parameters of fluid status including heart rate, systolic blood pressure, and diastolic blood pressure suggest that significant numbers of patients underwent excess ultrafiltration based on their traditional dry weight calculation. Thus, using IVC parameters before and during hemodialysis might give a better estimation of fluid status of the patient and guide the amount of ultrafiltration to be done. ","PeriodicalId":52856,"journal":{"name":"Nepalese Medical Journal","volume":"19 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2018-12-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88558179","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Intravenous fluids are a core element in the resuscitation of critically ill patients, and choice & management strategies vary widely in day-to-day medical practice. With the advancement in the understanding and implementation of aggressive fluid resuscitation, has also come a greater awareness of the resultant fluid toxicity. As such, the discussion regarding intravenous solutions continues to evolve especially as it pertains to their effect on kidney and metabolic function, electrolytes, and ultimately patient outcome. This review discusses the fluid management from the perspective of resuscitative strategies, and is expected to guide clinical practitioners in fluid decision-making for common clinical scenarios encountered at acute care setups.
{"title":"Intravenous Fluid Resuscitation: Breaking the Dilemma","authors":"A. Siddiqui","doi":"10.3126/NMJ.V1I2.21625","DOIUrl":"https://doi.org/10.3126/NMJ.V1I2.21625","url":null,"abstract":"Intravenous fluids are a core element in the resuscitation of critically ill patients, and choice & management strategies vary widely in day-to-day medical practice. With the advancement in the understanding and implementation of aggressive fluid resuscitation, has also come a greater awareness of the resultant fluid toxicity. As such, the discussion regarding intravenous solutions continues to evolve especially as it pertains to their effect on kidney and metabolic function, electrolytes, and ultimately patient outcome. This review discusses the fluid management from the perspective of resuscitative strategies, and is expected to guide clinical practitioners in fluid decision-making for common clinical scenarios encountered at acute care setups.","PeriodicalId":52856,"journal":{"name":"Nepalese Medical Journal","volume":"135 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2018-12-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86295822","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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