Here is a lecture I gave for the International Fluid Academy annual meeting which is truly a terrific event. Many of us have been working hard at ushering in this concept, which we feel is vastly more important than that of fluid responsiveness.
So I’ve been meaning to put this up for a while, along with many other #FOAMed lectures I want to share and get out there in our neverending quest to cut down on the KT on bedside physiological management. For years now I have enjoyed collaborating with my friend Curro Miralles, who is a fantastic clinician on top of being the latin leading man heir apparent to Antonio Banderas who somehow ended up as a physician instead. Well, medicine should be greateful! Enjoy!
It’s always a good time hanging with these guys (@khaycock2 and @Emnerd). Over the years I’ve learned a ton from them. Even if I thought I was pretty solid on something, they almost always have the ability to shed some additional light on it in a particularly useful way. So I always look forward to these discussions. Today we took some time to flesh out some of the questions and statements that came up about VExUS in the last few days on medtwitter.
So I’m finally getting around to listening to the #HR2022 lectures I hadn’t had a chance to prior to the conference – it gets busy – that so many are raving about, and this was a really good one. This dynamic NeuroCrit duo hit on a lot of really important principles, including one of my favorite myths, that of neuroprognosticating based on an ICH score. It truly is disenheartening to see, in my experience, how few neurosurgeons either acknowledge or are aware of this, and, particularly in young patients, the self-fulfilling prophecy concept could be making us miss opportunities to save lives.
Anyway, I won’t steal their thunder, so have a listen!
I’ll be releasing select HR2022 lectures every few weeks, and for those interested amazing lectures and in CME, you can find the rest here:
So after much deliberation, we have decided and are excited to bring the fourth edition of H&R back for 2022 – we had skipped 2021 to focus on some research papers and developing some courses (Flipping the Vent and The VExUS Course), but mostly because the virtual conferencing experience simply did not measure up to the live event. What makes boutique conferences like H&R so different (and awesome) is the similar mind-set of the faculty and the participants, the opportunity to interact and network, exchange and build. So much of what many of us have achieved in the last years was built on introductions, discussions and conceptual sparks that have led to publications, projects and most importantly, personal growth. Because at the heart of it, the H&R faculty – and I daresay the majority of the participants – is made up of individuals who are never satisfied with the status quo, and who are always looking to add to their knowledge and skills. It is incredibly stimulating to be surrounded by these people, and it is a growing family.
So due to the limitations and uncertainties of the very much active pandemic, there remain some question marks. One thing, however, that is without a doubt, is that we will put together some amazing content in a unique, hybrid format that will have everyone leave with a few more concepts and skills.
Where & When? Montreal, May 19th-21st, 2022, at the Montreal Heart Institute Conference Center (19th-20th) and Santa Cabrini Hospital (21st)!
Scientific Committee: Dr. Ross Prager, Dr. Carol Zambrana, Dr. Philippe St-Arnaud, Dr. Ian Ajmo, Dr. Philippe Rola, Dr. Andre Denault.
Credit Designation: This event was accreditated for a maximum of 60.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Here’s how it’s gonna go:
Pre- and Post- conference courseswill include
(1) The VExUS Course (F2F/Virtual)
(2) The Resuscitative TEE Workshop (May 21 – F2F Only)
(3) POCUS for the Hospitalist (May 18 – F2F Only)
(4) The REBOA Course
H&R Main Conference – will be divided into an online didactic set of lectures(two days worth!) divided into topic tracks such as cardiac arrest, POCUS, advanced hemodynamics, critical care pearls, airway management, sepsis, mechanical ventilation as well as a number of hospitalist tracks (POCUS for the Hospitalist, Spotlight on Nephro, COVID on the Wards, Surgical Issues for the Hospitalist and Hospitalist Pearls) and two live F2F conference days. Live participants will be strongly encouraged to watch the online lectures prior to coming to the F2F conference, which will consist of workshops (60% of the day) and “Long Conversations” (40% of the day) with 2-3 faculty members discussing various topics with the participants. Essentially the F2F conference will be 100% interactive, as the long conversations are meant to address the topics that don’t lend themselves well to, or require hands-on workshops (eg sepsis and complex hemodynamics). In a sense, this is letting the participants into what the most interesting part of past H&Rs has really been – the unscripted faculty behind-the-scenes discussions. I can say that for my part I always learned a tremendous amount in those moments, and always felt it would be fantastic to find a way to share these.
The Online Pre-Conference Programme:
The Live Conference Programme:
Why the Flipped Classroom?
The idea is to maximize the discussion and the workshops, all of whom will be tailored to the different tracks (POCUS, hemodynamics, airway, etc…), so that the participants really get a chance to extract the pearls from the faculty in those two days. Essentially, participants will get double the conference, without having to free up 4 calendar days (unless you plan to attend some of the courses)
Sadly, we are forced to limit the live participants to 80, in order to maintain social distancing for the Long Conversations. The pre- and post- conferences will also have limited participants. Also, in case there is a major wave obliterating travel and hosting capabilities, registrants will only be asked to pay a portion of the total fee in case it must be downgraded to a virtual-only event, so as to avoid the hassle and cost of refunds (we still have nightmares of the 2020 cancellation!). If all goes well the remainder of the live registration cost will be required 4 weeks prior to the event. So the F2F participants will have two sequential tickets to purchase. If you are only going for a virtual conference, there is only one ticket. You will be able to remotely watch the Long Conversations but not participate. Same concept for The VExUS Course, but the POCUS for Hospitalist and Resus TEE Workshop will be all or none for obvious reasons, fingers crossed. PLEASE NOTE THAT PRIORITY FOR COURSES IS GIVEN TO THE FULL CONFERENCE REGISTRANTS!
Main Conference F2F (May 19-20)- 1049+tx for physicians (849$+tx for CIUSSS EMTL, ICM Physicians, CISSS Laurentides and RLA Fellows): These are limited to 80 participants. This will give you access to the HR2022 Lectures on May 1st to watch on your own time prior to the live event.
Main Conference Online Only High Income Countries (HIC) – (299$+tx): This will give access to the HR2022 Lectures on May 1st, as well as online access to some of the live material on May 19-20.
Main Conference Online Special Rate (for trainees, allied health and physicians from low and middle income countries – 99$+tx): This will give access to the HR2022 Lectures on May 1st, as well as online access to some of the live material on May 19-20.
The VExUS Course Live (May 21 half-day AM – $399+tx): only 40 spots, reserve yours by emailing email@example.com, tickets available April 15th.
POCUS for Hospitalists (May 21 full day – 399+tx): only 40 spots, reserve yours by emailing firstname.lastname@example.org, tickets available April 15th.
So, more details to come in the next days, with the programme and the faculty, but this is what we have in mind, and we think it will be outstanding, so please wear masks, get your boosters (of course all faculty and participants will require proof of vaccination) and encourage everyone around you to do so in order to make this event and countless others happen!
Program & Faculty
Really excited about the preliminary programme that is growing day by day. Participants will get to see familiar faces and amazing educators such as grandmaster Andre Denault, Kylie Baker (@kyliebaker888) Korbin Haycock (@khaycock2), Rory Spiegel (@EMNerd), Peter Weimersheimer (@VTEMSONO), Felipe Teran (@FTeranMD), Lissa Ajjamada, Marco Garrone (@drmarcogarrone), Robert Chen (@ottawaheartrob), Scott Weingart (EMCrit himself!), Haney Mallemat (@criticalcarenow), Matt Siuba (@msiuba), Joe Nemeth, but also really excited to add some new faces like Katie Wiskar (@katiewiskar), Eduardo Argaiz (@ArgaizR), Neha Dangayach (@drdangayach), Abhilash Khoratala (@NephroP), Renee Dversdal (@DRsonosRD), Ashley Miller (@ICMteaching) and on top of it all, some critical care legends such as Glenn Hernandez (@AndromedaShock), Jan Bakker and Sheldon Magder…and more to come, got my fingers crossed!
So we had a blast with the VExUS Course a few weeks ago, it was really great to see how much enthusiasm and actual clinical use it is getting all over the world. Humbled, grateful and certainly feeling like the hard work was worth it to have this impact. So even after the workshop, there was a lot of questions, and some take more than a few lines to dig into, and since one participant, Dr. Rajiv Sinanan, a nephrologist, was so organized in his case questions, including a powerpoint with cases, I thought it was worth sharing. My life being busy and chaotic, I unfortunately had to do this on the way to work, so apologies for the audio and video quality! But I think there are some good pearls in there for those starting to use VExUS out there!
For those of you interested in learning more, we are hoping to soon have the ability to hold an in-person workshop, so we do not yet know when the next VExUS Course will be offered, but the online material is available here, and the cost of the online material + later workshop is the same as the full course. Going thru the material and getting some practice in may also help you by providing you with cases to discuss during the workshop.
While the last few months had quieted down, the last few weeks have seen a serious resurgence in COVID cases, particularly in the southern US and in south and southeast Asia. I cam across several really disturbing posts and tweets across medical SoMe about the lack of ECMO beds and cases of refractory hypoxia.
While TCAV(TM) will not save every COVID ARDS patient, in our experience it helps significantly, ideally from the get-go, but also in rescue after failure of traditional modes.
This is why we decided to add this date – sooner than planned – as it seems it may have clinical impact in the current pandemic.
I offered to share in a #FAOMed fashion the online portion of this course with anyone interested and currently struggling with COVID ARDS, but as a faculty we all feel that it is only a basic introduction, and that two other elements are ideally needed, the workshop (included in this course) and some case mentoring for the first few cases, which we are working on.
Registration fee will be waived for physicians from low-resource settings, please explain this in the email to email@example.com to obtain the registration link. Registration will be stretched to 30 participants in order to maintain a good level of interaction during the workshop.
To register: email hospresusconference@thinkingcriticalcare
So it is with gradual amazement and a great sense of accomplishment that we have witnessed the remarkable interest that our field of acute care has taken in VExUS. This has also been tempered by the humility of experience, as all of us have seen fads come and go, and also because an interventional approach based on VExUS is not yet evidence-based, as the studies remain to be done, some being underway. At the same time, it has been a good 4-5 years that most of those involved in the VExUS papers have been using Doppler-enhanced POCUS assessment of venous congestion. Our pragmatic and empiric experience has solidified in our minds the importance of venous congestion and the pitfalls in being oblivious to it. At the same time, we have some reservations about seeing it be used in a recipe form, with a “VExUS-furosemide reflex” which would NOT be how a bedside physiology tool should be used.
Hence, we decided to put this together, to be much more than a “how-to” – which to us has the risk of giving a tool without good instructions – but to be comprehensive in it scope, to take participants from pathophysiology thru ultrasound assessment and finally potential clinical application.
After the success of The APRV-TCAV(tm) Course, we have decided to follow the blueprint and make this a 6 hour, two part course, with a didactic online portion which participants are asked to complete prior to the live workshop, where we will present and discuss cases and the nuts and bolts of clinical management integrating VExUS to the global clinical assessment, POCUS and otherwise, which is how it should be used.
The idea is to come out of this with a solid understanding of venous congestion, the various means to assess it, and a clinical framework to implement into the management of these patients on a daily basis.
The Pilot Course (virtual): September 21, 2021, 1pm eastern time.
The first one, to work out the kinks, will have a token registration fee and limited to 40 participants. If you are a trainee or from a resource-limited area please let us know, we are reserving some complimentary spots. Registration will open at the end of July, so email firstname.lastname@example.org to be considered for a spot! Please include a short description of your practice to be considered for a spot. We are favouring acute care clinicians with POCUS experience as this is not a basic POCUS skill, and we want participants to be able to start using VExUS following the course.
Due to current travel restrictions and the uncertainty related to quarantine, this event will be virtual. We anticipate that further events will likely be live, and this course will likely be given during BeachResus and H&R2022.
Dr. Korbin Haycock (@khaycock2) – Riveside Health & Loma Linda University, CA, USA.
Dr. Rory Spiegel (@EMNerd) – Washington Medical Center, DC.
Dr. Philippe Rola (@ThinkingCC) – Santa Cabrini Hospital-CIUSSS-EMTL, Montreal, QC.
All three of us were part of the original VExUS study and have continued to expand the literature on the topic. We use POCUS and assess venous congestion on a daily basis. We have all been teaching via #FOAMed and live conferences for several years. We’re looking forward to share our experience with each participant.
So at the last Flipping the Vent course, we had the treat to have guest faculty Dr. Gary Nieman give us a lecture on the basic science and physiology behind the TCAV(TM) method, and it was really fantastic, so I just thought it was worth sharing with everyone.
While no ventilation technique will save every patient with severe lung injury, it is time to forge ahead and take steps towards improving the mortality of ARDS, COVID or otherwise, which has stagnated in the last 15 plus years. While ARMA established that 6 ml/kg was better than 12 ml/kg, it really showed little else. By no means can that data be interpreted as being THE best way to ventilate EACH patient, but only that low VT is better than high VT.
We know that driving pressure correlates with mortality. We know that atelectrauma, more so than volu- or baro-trauma, is the main engine behind VILI. Hence those are the things we should be trying to minimize.
So for me, the first wave (spring 2020 for Montreal) was the early proving grounds for APRV-TCAV in COVID-19 respiratory failure, and now in the second wave, we are fine-tuning the approach. For Rory Spiegel in Washington, the first wave blended smoothly into the second and he has accumulated a ton of COVID APRV TCAV experience. From our experience, steadily growing since last spring, this is the go-to mode for the vast majority of COVID-19 cases requiring mechanical ventilation.
Rory and I have been joined by two other faculty members who are equally passionate about teaching APRV-TCAV, and we will try to get some awesome guest lecturers for each iteration of the course.
BREAKING NEWS! We are incredibly happy to announce that we will have an amazing guest lecturer for this edition of the APRV-TCAV course, Dr. Gary Nieman, one of the architects of the TCAV methods, and he will be joining us to deliver a lecture on the physiology of the TCAV principles!
At H&R Reloaded, Rory presented “Flipping the Vent,” essentially a conceptual intro to APRV-TCAV, and we ran a small group workshop, which we also did at Haney’s ResusX, which were really enjoyable, and it seems the participants really came away with a lot, but also a lot of questions. So we figured we’d put together a more comprehensive course to give participants a solid base to start using this mode of ventilation.
The first course was essentially held for the Mayo Clinic’s anasthesia/critical care fellows and RTs and included a team from Ireland as well as a handful of individual participants, and was a success. Hence we give it another run!
This course will consist of an online portion (3h core material as well as supplementary material) done at each participant’s convenience, and a live workshop (3h) on the day of the course, but we are adding to the online curriculum, and participants will have ongoing access to the additional material for a year following the course. We are strongly suggesting participants go through at least the core material, because without a reasonable understanding of APRV-TCAV, the workshops will be very difficult to follow and benefit from.
The workshop is the really awesome part of this course, and will mainly feature in-depth case discussions and where we get to the nitty-gritty and review decisions along the course of management of APRV ventilation. This is where the understanding of how to adjust your ventilation as your patient progresses thru different phases of illness, how to escalate or progress to weaning, and how to troubleshoot along the way.
We will finish with an examination to make sure that the concepts have really gotten across.
“Coffee or a deep interest in ventilation modes is a must if logging onto this course from Europe – the Q&A piece is in the wee hours! Attending this course as a group helped us gain confidence to try APRV-TCAV in the difficult to ventilate COVID-19 patient (We have Draeger ventilators but had not used the TCAV version of the mode before with the 75% PEF setting in the “additional settings” part of the vent). Dr Rola and Dr Spiegel simplified complex concepts. They got us to trouble-shoot problems. I would recommend this course.” (Dr. Catherine Nix, Anaesthetist-Intensivist)
“Flipping the Vent APRV-TCAV was an excellent introduction to this mode of ventilation, delivered in a practical and useful manner. The rationale is clearly explained at the outset and this is built upon throughout, with discussion around exactly how the ventilator and patient are managed using relevant case scenarios. The expertise of the educators on this course make APRV-TCAV accessible for those unfamiliar with it. I have a better understanding of the practical application of APRV-TCAV having attended this course” Dr Cathal Mac Donncha,Critical Care Fellow.
Registration: due to the rapid sell-out of the last course, we have a long waiting list and we will advise those on it to give them first registration opportunity.
Special Circumstances: we understand that many physicians who may wish to attend and benefit from learning may be in different socio-economic situations, and of registration fee is an issue, please email us at email@example.com, and we will do our best to accommodate you. Drs. Spiegel and Rola put a high value to knowledge translation and sharing of skills and information.
The Waiting List: please email firstname.lastname@example.org and let the team you wish to be on the list know in case some spots open up.
Sponsors: we are always looking for sponsors to provide scholarships to physicians or other health care professionals trying to learn. Please contact us if you are able to sponsor one or more!
Schedule (Online module):
Part One – APRV-TCAV Basics (3h) OnLine Module (participants will receive access link with registration)