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Abstract. Intradialytic hypotension (IDH) is the most common complication of hemodialysis. Symptomatic IDH requires the administration of fluid and often results in the early termination of dialysis, both of which may prevent adequate fluid removal. The optimal fluid for the treatment of IDH remains unknown. A randomized, double-blind, crossover trial was performed in 72 chronic hemodialysis patients to determine whether 5% albumin was more effective than normal saline for the treatment of IDH. The primary outcome measure was the percentage of target ultrafiltration achieved, which was defined as the actual ultrafiltration volume divided by target ultrafiltration volume. Secondary outcome measures included postdialysis BP, time to restore BP, recurrent IDH, and treatment failure (inability to restore BP with 750 ml of study fluid). The percentage of target ultrafiltration achieved was 0.84 Ϯ 0.17 for 5% albumin compared with 0.80 Ϯ 0.16 for saline (P ϭ 0.14). The postdialysis systolic BP (121 Ϯ 19 mmHg versus 117 Ϯ 19 mmHg; P ϭ 0.32), postdialysis diastolic BP (63 Ϯ 9 mmHg versus 61 Ϯ 9 mmHg; P ϭ 0.33), volume of study fluid used to treat IDH (403 Ϯ 170 ml versus 428 Ϯ 191 ml; P ϭ 0.34), time required to restore the BP (7.9 Ϯ 6.6 min versus 9.9 Ϯ 7.5 min; P ϭ 0.09), total nursing time required to manage the hypotensive episode (15.1 Ϯ 7.2 min versus 15.9 Ϯ 7.3 min; P ϭ 0.47), number of treatment failures (22% versus 24%; P ϭ 1.0), and the frequency of recurrent IDH (36% versus 36%) were not significantly different when 5% albumin was used compared with saline. It is concluded that 5% albumin is no more effective than normal saline for the treatment of IDH in chronic hemodialysis patients. Normal saline should be used as the initial fluid for the treatment of IDH.

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BackgroundPediatric residents must become proficient with performing a lumbar puncture (LP) during training. Residents have traditionally acquired LP skills by observing the procedure performed by a more senior resident or staff physician and then attempting the procedure themselves. This process can result in variable procedural skill acquisition and trainee discomfort. This study assessed changes in resident procedural skill and self-reported anxiety when residents were provided with an opportunity to participate in an interactive training session and practice LPs using a simulator.MethodsAll pediatric residents at our institution were invited to participate. Residents were asked to report their post-graduate year (PGY), prior LP attempts and self-reported anxiety scores as measured by the standardized State-Trait Anxiety Inventory - State Anxiety Scale (STAI-S) prior to completing an observed pre-test using an infant-sized LP simulator. Staff physicians observed and scored each resident’s procedural skill using a previously published 21-point scoring system. Residents then participated in an interactive lecture on LP technique and were given an opportunity for staff-supervised, small group simulator-based practice within 1 month of the pre-test. Repeat post-test was performed within 4 months.ResultsOf the pediatric residents who completed the pre-test (N = 20), 16/20 (80 %) completed both the training session and post-test. Their PGY training level was: PGY1 (38 %), PGY2 (25 %), PGY3 (25 %) or PGY4 (12 %). Procedural skill improved in 15/16 residents (paired t-test; p < 0.001), driven by a significant improvement in skill for residents in PGY1 (P = 0.015) and PGY2 (p = 0.003) but not PGY3 or PGY4. Overall anxiety scores were higher at baseline than at post testing (mean ± SD; 44.8 ± 12.1 vs 39.7 ± 9.4; NS) however only PGY1 residents experienced a significant reduction in anxiety (paired t-test, p = 0.04).ConclusionLP simulation training combined with an interactive training session may be a useful tool for improving procedural competence and decreasing anxiety levels, particularly among those at an earlier stage of residency training.

The bilateral 45 degrees PA is superior for detecting lateral compartment wear but offers no advantage on the medial side. This view should be considered as the screening radiograph of choice in evaluating osteoarthritis of the knee.

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