The NYC Tracks with Jon-Emile part 2: a discussion on congestion, pulmonary and otherwise. #FOAMed, #FOAMcc, #FOAMus

So here is our second discussion, where we delve a bit into diuretic physiology, the issue of organ congestion, the myth of the “low-flow” acute renal failure associated with CHF (see earlier post), and a couple other things including a great way to determine if a patient isn’t respecting the low salt diet prescription!

I meant to, but forgot to discuss with Jon what I think is an important end-point in CHF management: the IVC. Yes, it is useful not just to make the diagnosis of congestion, but also target normalization of IVC physiology prior to discharge. It just makes common sense. If you decongest a patient just enough to get them off O2 and send them home, they bounce back a lot quicker than if you make sure you’re given them some intravascular leeway.  How do you determine this? Simple enough, make sure your IVC is down at least to below 20mm, and has recovered the classic acxvy and respiratory variation. I personally try to get into the 8-12 mm range, but that’s arbitrary. Here is some good data for 20mm:

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Without further due, here is the NYS Track 2:

 

Please share your thoughts!

 

cheers

 

Philippe

The NYC Tracks with Jon-Emile: Paracentesis and Volume Status. #FOAMed, #FOAMcc, #FOAMus

So I was in NYC last week and met up with my buddy Jon-Emile Kenny, (@heart_lung), intensivist-physiologist extraordinaire, and we recorded a few discussions on practical matters.

I always love to debunk myths and avoid dogmatic guesswork, and, more often than not, Jon, with his encyclopedic knowledge of the physiology literature, but more importantly a cutting edge understanding of it, can back up my vague ideas and empirically derived ideas, so that the next time someone asks me why this is so, I can have a semi-enlightened answer!

So here is the first, where we discuss the common question about the need (or not) of intravascular volume repletion during or following large volume paracentesis. Yes, there are some formulas out there as to how much albumin or crystalloid one should give, due to the worry of subsequent hypovolemia. Note how those formulas use no data about your patient’s volume status at the time of paracentesis, so as far as I’m concerned, they have no value whatsoever in an era where we can assess this. Yes, ultrasound is the base as far as I’m concerned.

Here we go:

Please share your thoughts!

cheers

 

Philippe

Wicked bedside US case from a CCUS Fellow! #FOAMed, #FOAMus

So a few weeks ago I was glad to meet the latest of the CCUS Fellows, Dr. Mathieu Brunet. This guy practices in the Magdalen Islands, and came to spend 3 days with me in the ICU to sharpen his bedside ultrasound skills. In fact, his technicals skills were already very good, so we spent most of the time reviewing how one integrates the bedside ultrasound data into clinical practice. We overlapped a fair bit into critical care management and resuscitation, naturally.

Well, a couple of weeks later, he tells me about a great case he’d had where he was already able to apply some of the skills he’s sharpened:

Hi Philippe,

I had this trauma case this week that I think highlights once again the usefullness of POCUS in making meaningful and timely bedside clinical decisions. Unfortunately, I didn’t save the images…

A 50 year old man was brought in by EMS after a 4 meter fall. He had isolated TBI and presented with a glascow of 5 (decorticating). An obvious right temporal deformity and a right fixed mydriasis were noted in the primary survey. My initial thoughts in the context of TBI was ongoing uncal engagement…a poor prognosis sign to say the least. However I noticed in the secondary survey a significant right periorbital ecchymosis with what seems to be a stint of exophtalmia. Was the bleeding solely preseptal, or could a retrobulbar hematoma explains the mydriasis? I reached for the ultrasound while anesthesia was intubating and was able to visualise black hypoechoic fluid in the retroorbital area. I promptly proceded to do a lateral canthotomy and a few minutes later both pupils were equal and reactive! This completly changed the momentum of the rescucitation since we were now looking at a patient with a much better prognosis then an actively herniating one! POCUS also resulted in a much shorter occular ischemia time since there would have been a significant delay if discovered only by the radiologist on CT scan.

Also, I was able to record a baseline internal carotid doppler waveform in the first minutes of rescucitation showing a markedly reduced diastolic flow (wasn’t able to find a vessel by TCD). I subsequently noticed improvement of the waveform following administration of mannitol which prompted me to be more agressive on the hyperosmolar therapy (started an hypertonic saline drip) despite the absence of clinical improvement at that time. In the next few hours, the patient waveforms further improved and the patient started withdrawing to pain.

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The patient eventually transfered to the level one trauma center and unfortunately passed away a few days later in the neuro-ICU.

I thought that the case illustrates interesting applications of POCUS in the management of TBI and facial trauma:

1) Quick confirmation of orbital compression which can be mistaken for a third cranial nerve compression. This can be sight saving since irreversible damage occurs after 60 minutes of ischemia.
2) Assessment of the response to hyperosmolar therapy before clinical response is apparent, or in the paralysed patient.

Please share your thoughts!

Mathieu

 

Great job Mathieu, even if all can’t be saved. Tough case. Never having done a canthotomy, lateral or otherwise, I’m glad it was you and not me! One a serious note, I wonder if this patient had a decompressive craniotomy, which seems the only physiological therapy for the “brain compartment syndrome”  we too often seem to try to treat medically.

I completely agree with your POCUS points. Too often naysayers (always those who can’t do POCUS) say “well, we would have found it on the CT, so this ultrasound stuff really isn’t necessary.”  That is fine when time is not of the essence. In acute care, it is.

Another key point is the even greater utility of POCUS in remote areas of practice such as yours, where resources are limited, and the decision to transfer must be done rapidly and accurately.

But great use of CNS POCUS indeed. Next time save the pics and clips!!!

 

cheers

 

Philippe

Fluids in Sepsis: An EmCrit Webinar! #FOAMed, #FOAMcc

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So a few weeks ago Scott (@EmCrit) asked me to be part of a pretty cool webinar organized by the Greater New York Hospital Association about fluids in sepsis. The gang consisted of David Gaiesky, Emmanuel Rivers and moderated by Scott himself. And for some obscure reason, he asked me to be part of it – much to my honour (terror, also), naturally.  It was only afterwards that he told me it was to help stir the pot and be controversial, challenge the “old school” etc… He seemed to have overlooked that I am Canadian, and inherently and perhaps overly polite and considerate – at least live and in “person”!

We talk about a bunch of stuff around fluids, which, how much, how to assess, etc.

Anyhow, I hope I got a few ideas across, but it was really cool to hear that these gurus do use ultrasound – don’t necessarily strictly adhere to, for instance, EGDT, and also advocate that guidelines are guidelines and not necessarily gold standards.

Here is the link to the webinar for those interested:

 

https://t.co/dbL03Vuqlj

 

And here is the figure for the section where I refer to fluid responsiveness/tolerance:

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I further talk about this in a previous post here.

Scott and I also recorded a debrief which should be coming up in the next weeks on EmCrit – link to follow!

cheers!

 

Philippe

CCUS Institute Bedside Ultrasound Mini-Fellowships. #POCUS

Intro

The personalized CCUS Institute’s Mini-Fellowships are focused on bedside ultrasound are designed to take clinicians with some degree of proficiency in basic ultrasound to a whole other level. The opportunity to follow a seasoned clinical ER/ICU sonographer and see actual cases, learn the clinical integration of ultrasound data into decision-making is a unique one, outside of a handful of residency programs whose faculty includes experienced bedside sonographers. Basic how-to courses are great, and certainly the first step for those clinicians adding ultrasound to their armamentarium, but what we have seen, sadly, is after initial enthusiasm, many don’t really pick up the probe because the confidence to “make the call” simply isn’t there. Yet.

In a sense, it’s almost as if, as medical students, we’d read Bates, practiced physical exam on each (more or less normal ) other, and were then set out to make diagnoses and treat without having residents and attendings around to confirm our findings a few times, until we got the hang of it. Hmm. That would be rough.

Some physicians are fortunate enough to practice in a center where there are a few “veterans” of bedside ultrasound and can gain some acumen that way, but others may be the ones spearheading their institution into the 21st century, and it is from the comments of several of those, attending the CCUS Symposium (2008-2014 – perhaps a return in 2017) asking for the possibility of shadowing some of us, that the Mini-Fellowships came to be.

 

Mini-Fellowship Structure

Participants shadow one of our instructors (ICU attending) during the regular working days and discuss the cases and ultrasound-relevant aspect of each case (more often than not the case in entirety), and are able to practice their ultrasound skills. The duration is flexible although we generally suggest a minimum of two or three days. Each day would usually be about 6 hours, some may be more. The case exposure will be mainly ICU as well as ER and ward patients. The focus will be on acute care issues. After two days, participants who had a basic ability in ultrasound should be fairly comfortable with assessing volume status, cardiac function, perform lung ultrasound, be able to identify and assess intrathoracic and intr-abdominal fluid collections, assess the kidneys, bladder and gall bladder, measure optic nerve sheath, assess carotid flow and some may have exposure to trans-cranial doppler. The focus may be shifted depending on a participant’s interest.

Participants will have the opportunity to work with handhelds, midrange and high-end ultrasound devices.

Space is limited as we can generally only accommodate 1-2 participants per month.

 

Requirements 

Please have basic experience in bedside ultrasound. We don’t want to teach you about depth and gain. We’re happy to fine tune your views but not to introduce you to the main cardiac views. It would just be wasting your clinical time. We’re here to show you how to assess pathology and integrate your findings into clinical decision-making. Take the basic group course to learn the views, or be self-taught from youtube/iphone and practicing on your patients. You don’t have to be great, but to get the most out of this experience it shouldn’t be your first time holding a probe.

 

Registration

email us!

 

Tuition

450$ per day.

100% refundable until you start. Even if you don’t show up. Really. We’re not in it for the business. We get to go home earlier if you don’t come.

 

CME

Coming soon.

 

Testimonials:

“Thank you very much for the exposure and teaching offered via the CCUS “Mini-Fellowship.”  These few days allowed me to enormously improve my mastery of bedside ultrasound in clinical decision-making in critical care. I recommend the experience to clinicians already having experience in bedside ultrasound, but who feel they could benefit from the expertise of an instructor to attain a level beyond basic courses and available textbooks.”

Mathieu Brunet, MD, GP/ER/ICU, Magdalen Islands, Quebec, Canada

 

“The CCUS Mini Fellowship In House training is very essential in to experience the echo skills that we get from the courses,being supervised in ICU will offer the chance to be corrected and get real live practice/exposure by being at the bedside and learn what is priority in echo for the best of patient care. The in-house experience is very helpful, practical, I recommend this training to any physician involved in ER, ICU, CCU, Anesthesia and rapid response team.”

Joe Choufani, MD, Internal Medicine/Cardiology, St-Lawrence Health Association, NY

 

“Thanks for everything. I really appreciate you sharing your vast fund of knowledge with me.”

Sean Sue, MD, ER, Philadelphia

Bedside US Procedure: Pericardial drainage – Pearls! #FOAMed, #FOAMcc, #FOAMus

So here is a video of a pericardial drain placement for pre-tamponade in a 33 yr old man, presumptively for a viral pericarditis (cultures and cytology pending).  In this case, the approach was subxiphoid, because this offered a large pocket of fluid with little or no risk of hitting the RV. The apical approach would have been more risky. Due to technical issues, the video only starts once the guide wire is already in place, but there are a couple of teaching points worth sharing nonetheless.

First, it is useful to confirm guide wire placement prior to dilating. Secondly, in cases such as this where the distance to the pericardium is more than a couple of centimetres (it was about 6 cm here), it is nice to be able to confirm under real-time that the dilator is indeed in the intended area. Because the guide wire is highly echogenic, and the dilator is not, one can see the proximal part of the guide wire “disappear” which indicates that the dilator has covered it, now visibly in the effusion. Once the pigtail is  inserted over the guide wire, final confirmation can be obtained by injecting back thru the pigtail and seeing echogenic material (due to minute amounts of air) appear in the pericardium. This is known as the Ajmo sign.

Cheers!

 

Philippe

Test Drive: GE’s New VScan! #FOAMus

I recently had the chance to try out the gen 2 VScan, since my original one, which replaced my stethoscope 4 years ago, suffered from trauma and is currently in a GE operating room undergoing serious surgery.

GE was kind enough to give me a replacement and have me give their next generation a go, so I thought it would be nice to give a little review for potential buyers.

First of all let me put it in perspective. When GE approached me to try the original VScan in 2011, I thought it was a cool toy, but, as an avid sonographer who tended to favour potent devices as opposed to the smaller laptop-based ones, I didn’t expect to fall for the ‘limited’ VScan.  They thought I might.

Turned out we were both right. If I had one of Santa’s elves pushing my ICU’s Aloka Alpha 7 behind me, handing me a clean probe and following me around, plugging and unplugging the awesome but bulky device, I would have no need for a VScan. However, I have yet to hear back from the North Pole, and in its absence, the VScan has been an absolutely awesome and indispensable tool. I’m not joking. My stethoscope has joined my antique medical instruments collection (which includes some really cool ancient metallic tracheostomy tubes btw). I use one of this plastic disposable ones if I really, really want to listen for a wheeze (although I find the degree of expiratory phase prolongation to me a much more sensitive sign of outflow limitation…).

I use the VScan every day, for almost every patient. Bedside ultrasound is an integral part of the physical examination one follow up. It beats guessing.

In my experience, it does the trick about 80% of the time. For more challenging patients, or for a more exhaustive examination, I push that Aloka myself. But when following up patients on the wards especially, having the VScan in my pocket is absolutely essential. Not having it is borderline unethical if I’m dealing with genuinely sick patients.

So the new device has a dual probe with vascular and surface capabilities, which is pretty cool, especially if the physician using it has no other device, as vascular exam is really important for procedures and for lung ultrasound (the gen 1 VScan will see B lines but doesn’t have the resolution to look for lung sliding. Here, I’m using the gen 2 on the wards with a sterile sleeve to drain an intra-abdominal hematoma.

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So is this a plug for the VScan?  Not really. For bedside ultrasound? Absolutely. Every physician taking care of acutely ill patients should have some form of immediately available ultrasound. Anything else is short-changing your patient of the best care they can get.

My favorite article to illustrate the need to integrate bedside ultrasound in daily examination is the following, where novice medical students with ultrasound blow away seasoned, board-certified cardiologists in cardiac diagnosis:

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Keep in mind that you can still be a great clinician without bedside ultrasound. But you can be a better one with it.

 

cheers!

 

Philippe

 

p.s. thanks to Mr. Pascal Langlois of GE for the gen 2 VScan loaner!