Worry as Important "Feelers" in Clinical Anesthesia Practice: A Mixed-Methods Study.

PURPOSE: Worry is an intuitive sense that goes beyond logical reasoning and is valuable in situations where patients' conditions are rapidly changing or when objective data may not fully capture the complexity of a patient's situation. Nurse anesthetists' subjective reasons for worry are quite vague as they are valued inconsistently and not accurately expressed. This study aimed to identify factors playing a role in the emergence of worry during anesthesia practice to clarify its concept. DESIGN: Mixed-methods design consisting of quantitative online surveys followed by qualitative focus group interviews including Dutch nurse anesthetists. METHODS: Both quantitative and qualitative thematic analyses were performed, followed by data and methodological triangulation to enhance the validity and credibility of findings and mitigate the presence of bias. FINDINGS: Surveys (N = 102) were analyzed, and 14 nurse anesthetists participated in the focus group interviews. A total of 89% of the survey respondents reported that at least once have had the feeling of worry, of which 92% use worry during clinical anesthesia practice. Worry was mentioned to be a vital element during anesthesia practice that makes it possible to take precautionary actions to change the anesthetic care plan in a changing situation or patient deterioration. CONCLUSIONS: While a clear definition of worry could not be given, it is a valuable element of anesthesia practice as it serves as a catalyst for critical thinking, problem-solving, clinical reasoning, and decision-making. Use of the feeling of worry alongside technological systems to make an informed decision is crucial. Technology has significantly improved the ability of health care providers to detect and respond to patient deterioration promptly, but it is crucial for nurse anesthetists to use their feeling of worry or intuition alongside technological systems and evidence-based practice to ensure quick assessments or judgments based on experience, knowledge, and observations in clinical practice.

The Prognostic Role of Global Longitudinal Strain and NT-proBNP in Heart Failure Patients Receiving Cardiac Resynchronization Therapy.

BACKGROUND: We aimed to evaluate whether baseline GLS (global longitudinal strain), NT-proBNP, and changes in these after cardiac resynchronization therapy (CRT) can predict long-term clinical outcomes and the echocardiographic-based response to CRT (defined by 15% relative reduction in left ventricular end-systolic volume). METHODS: We enrolled 143 patients with stable ischemic heart failure (HF) undergoing CRT-D implantation. NT-proBNP and echocardiography were obtained before and 6 months after. The patients were followed up (median: 58 months) for HF-related deaths and/or HF hospitalizations (primary endpoint) or HF-related deaths (secondary endpoint). RESULTS: A total of 84 patients achieved the primary and 53 the secondary endpoint, while 104 patients were considered CRT responders and 39 non-responders. At baseline, event-free patients had higher absolute GLS values (p < 0.001) and lower NT-proBNP serum levels (p < 0001) than those achieving the primary endpoint. A similar pattern was observed in favor of CRT responders vs. non-responders. On Cox regression analysis, baseline absolute GLS value (HR = 0.77; 95% CI, 0.51-1.91; p = 0.002) was beneficially associated with lower primary endpoint incidence, while baseline NT-proBNP levels (HR = 1.55; 95% CI, 1.43-2.01; p = 0.002) and diabetes presence (HR = 1.27; 95% CI, 1.12-1.98; p = 0.003) were related to higher primary endpoint incidence. CONCLUSIONS: In HF patients undergoing CRT-D, baseline GLS and NT-proBNP concentrations may serve as prognostic factors, while they may predict the echocardiographic-based response to CRT.

The impact of the catheter to vein ratio on peripheral intravenous cannulation success, a post-hoc analyses.

BACKGROUND: Intravenous cannulation is usually the first procedure performed in modern healthcare, although establishing peripheral intravenous access is challenging in some patients. The impact of the ratio between venous diameter and the size of the inserted catheter (catheter to vein ratio, CVR) on the first attempt success rate can be of added value in clinical. This study tries to give insight into the consideration that must be made when selecting the target vein and the type of catheter, and proved the null hypothesis that an optimal CVR would not be associated with increased first attempt cannulation success. METHODS: This was a post-hoc analyses on adult patients admitted for peripheral intravenous cannulation. Intravenous cannulation was performed according to practice guidelines, by applying the traditional landmark approach. The CVR was calculated afterwards for each individual patient by dividing the external diameter of the inserted catheter by the diameter of the target vein, which was multiplied by 100%. RESULTS: In total, 610 patients were included. The median CVR was 0.39 (0.15) in patients with a successful first attempt, whereas patients with an unsuccessful first attempt had a median CVR of 0.55 (0.20) (P<0.001). The optimal cut-off point of the CVR was 0.41. First attempt cannulation was successful in 92% of patients with a CVR<0.41, whereas as those with a CVR>0.41 had a first attempt success rate of 65% (P<0.001). CONCLUSION: This first introduction of the CVR in relation to cannulation success should be further investigated. Although, measuring the venous diameter or detection of a vein with a specific diameter prior to cannulation may increase first attempt cannulation success.

Intelligent checklists improve checklist compliance in the intensive care unit: a prospective before-and-after mixed-method study.

BACKGROUND: We examined whether a context and process-sensitive 'intelligent' checklist increases compliance with best practice compared with a paper checklist during intensive care ward rounds. METHODS: We conducted a single-centre prospective before-and-after mixed-method trial in a 35 bed medical and surgical ICU. Daily ICU ward rounds were observed during two periods of 8 weeks. We compared paper checklists (control) with a dynamic (digital) clinical checklist (DCC, intervention). The primary outcome was compliance with best clinical practice, measured as the percentages of checked items and unchecked critical items. Secondary outcomes included ICU stay and the usability of digital checklists. Data are presented as median (interquartile range). RESULTS: Clinical characteristics and severity of critical illness were similar during both control and intervention periods of study. A total of 36 clinicians visited 197 patients during 352 ward rounds using the paper checklist, compared with 211 patients during 366 ward rounds using the DCC. Per ICU round, a median of 100% of items (94.4-100.0) were completed by DCC, compared with 75.1% (66.7-86.4) by paper checklist (P=0.03). No critical items remained unchecked by the DCC, compared with 15.4% (8.3-27.3) by the paper checklist (P=0.01). The DCC was associated with reduced ICU stay (1 day [1-3]), compared with the paper checklist (2 days [1-4]; P=0.05). Usability of the DCC was judged by clinicians to require further improvement. CONCLUSIONS: A digital checklist improved compliance with best clinical practice, compared with a paper checklist, during ward rounds on a mixed ICU. CLINICAL TRIAL REGISTRATION: NCT03599856.

The Modified A-DIVA Scale as a Predictive Tool for Prospective Identification of Adult Patients at Risk of a Difficult Intravenous Access: A Multicenter Validation Study.

Peripheral intravenous cannulation is the most common invasive hospital procedure but is associated with a high failure rate. This study aimed to improve the A-DIVA scale (Adult Difficult Intra Venous Access Scale) by external validation, to predict the likelihood of difficult intravenous access in adults. This multicenter study was carried out throughout five hospitals in the Netherlands. Adult participants were included, regardless of their indication for intravenous access, demographics, and medical history. The main outcome variable was defined as failed peripheral intravenous cannulation on the first attempt. A total of 3587 participants was included in this study. The first attempt success rate was 81%. Finally, five variables were included in the prediction model: a history of difficult intravenous cannulation, a difficult intravenous access as expected by the practitioner, the inability to detect a dilated vein by palpating and/or visualizing the extremity, and a diameter of the selected vein less than 3 millimeters. Based on a participant's individual score on the A-DIVA scale, they were classified into either a low, moderate, or high-risk group. A higher score on the A-DIVA scale indicates a higher risk of difficult intravenous access. The five-variable additive A-DIVA scale is a reliable and generalizable predictive scale to identify patients at risk of difficult intravenous access.

RegressionExplorer: Interactive Exploration of Logistic Regression Models with Subgroup Analysis.

We present RegressionExplorer, a Visual Analytics tool for the interactive exploration of logistic regression models. Our application domain is Clinical Biostatistics, where models are derived from patient data with the aim to obtain clinically meaningful insights and consequences. Development and interpretation of a proper model requires domain expertise and insight into model characteristics. Because of time constraints, often a limited number of candidate models is evaluated. RegressionExplorer enables experts to quickly generate, evaluate, and compare many different models, taking the workflow for model development as starting point. Global patterns in parameter values of candidate models can be explored effectively. In addition, experts are enabled to compare candidate models across multiple subpopulations. The insights obtained can be used to formulate new hypotheses or to steer model development. The effectiveness of the tool is demonstrated for two uses cases: prediction of a cardiac conduction disorder in patients after receiving a heart valve implant and prediction of hypernatremia in critically ill patients.

Development of the A-DIVA Scale: A Clinical Predictive Scale to Identify Difficult Intravenous Access in Adult Patients Based on Clinical Observations.

Placement of a peripheral intravenous catheter is a routine procedure in clinical practice, but failure of intravenous cannulation regularly occurs. An accurate and reliable predictive scale for difficult venous access creates the possibility to use other techniques in an earlier time frame. We aimed to develop a predictive scale to identify adult patients with a difficult intravenous access prospectively: the A-DIVA scale. This prospective, observational, cross-sectional cohort study was conducted between January 2014 and January 2015, and performed at the department of anesthesiology of the Catharina Hospital (Eindhoven, The Netherlands). Patients 18 years or older were eligible if scheduled for any surgical procedure, regardless ASA classification, demographics, and medical history. Experienced and certified anesthesiologists and nurse anesthetists routinely obtained peripheral intravenous access. Cannulation was performed regarding standards for care. A failed peripheral intravenous cannulation on the first attempt was the outcome of interest. A population-based sample of 1063 patients was included. Failure of intravenous cannulation was observed in 182/1063 patients (17%). Five variables were associated with a failed first attempt of peripheral intravenous cannulation: palpability of the target vein (OR = 4.94, 95% CI [2.85-8.56]; P < 0.001), visibility of the target vein (OR = 3.63, 95% CI [2.09-6.32]; P < 0.001), a history of difficult peripheral intravenous cannulation (OR = 3.86, 95% CI [2.39-6.25]; P < 0.001), an unplanned indication for surgery (OR = 4.86, 95% CI [2.92-8.07]; P < 0.001), and the vein diameter of at most 2 millimeters (OR = 3.37, 95% CI [2.12-5.36]; P < 0.001). The scoring system was applied in 3 risk groups: 36/788 patients (5%) suffered from a failed first attempt in the low-risk group (A-DIVA score 0 or 1), whereas the medium (A-DIVA score 2 or 3) and high-risk group (A-DIVA score 4 plus), included 72/195 (37%) and 74/80 (93%) patients with a failed first attempt of inserting a peripheral intravenous catheter, respectively. The additive 5-variable A-DIVA scale is a reliable predictive rule that implies the probability to identify patients with a difficult intravenous access prospectively. Dutch Trial Register (ref: 4595).

Irreversible electroporation for nonthermal tumor ablation in the clinical setting: a systematic review of safety and efficacy.

PURPOSE: To provide an overview of current clinical results of irreversible electroporation (IRE), a novel, nonthermal tumor ablation technique that uses electric pulses to induce cell death, while preserving structural integrity of bile ducts and vessels. METHODS: All in-human literature on IRE reporting safety or efficacy or both was included. All adverse events were recorded. Tumor response on follow-up imaging from 3 months onward was evaluated. RESULTS: In 16 studies, 221 patients had 325 tumors treated in liver (n = 129), pancreas (n = 69), kidney (n = 14), lung (n = 6), lesser pelvis (n = 1), and lymph node (n = 2). No major adverse events during IRE were reported. IRE caused only minor complications in the liver; however, three major complications were reported in the pancreas (bile leak [n = 2], portal vein thrombosis [n = 1]). Complete response at 3 months was 67%-100% for hepatic tumors (93%-100% for tumors o 3 cm). Pancreatic IRE combined with surgery led to prolonged survival compared with control patients (20 mo vs 13 mo) and significant pain reduction. CONCLUSIONS: In cases where other techniques are unsuitable, IRE is a promising modality for the ablation of tumors near bile ducts and blood vessels. This articles gives an extensive overview of the available evidence, which is limited in terms of quality and quantity. With the limitations of the evidence in mind, IRE of central liver tumors seems relatively safe without major complications, whereas complications after pancreatic IRE appear more severe. The available limited results for tumor control are generally good. Overall, the future of IRE for difficult-to-reach tumors appears promising.