TCD in the ED? A discussion with Jeff Scott. #FOAMed #FOAMer #FOAMcc

So a couple weeks ago I had the chance to sit in sunny Florida with Jeff Scott (@jsemccm), an ED-intensivist who runs the ED at Jackson South in Miami as well as rounding in the ICU at Jackson Memorial.

His group recently published an awesome article on TCD that pretty much made me realize I have to up my TCD game to the next level.

Here it is (unfortunately walled…)

And here is our discussion:

So there clearly is more to be done with TCD than I have been doing, and maybe it really has a place in the ED. I don’t work first line in the ED so initial stroke patients I only see if they deteriorate, but the idea of visualizing perfusion – or reperfusion – is really interesting.

So if you want to meet Jeff and have him teach you some POCUS TCD, don’t miss H&R2019 which is just around the corner. There aren’t many spots left! Jeff will be running a TCD workshop along with Rob Chen (@ottawaheartrob) which I’m really looking forward to!

Love to hear from anyone pushing the envelope of TCD (or any POCUS application). I believe we are only scratching the surface of what we can do with POCUS, and much study, based on front-line clinicians taking bold strides ahead to see what can be done.

 

cheers

 

Philippe

 

My friend, the IVC. #FOAMed, #FOAMer, #FOAMus, #FOAMcc

So I keep hearing and seeing people bash the IVC. Casually dismissing it with a shrug. “It’s not really good for volume responsiveness, you know…”

All that deserves is an eyeball-rolling emoji. That is, unfortunately, the reaction of docs who are trying to devise a threshold or recipe-based approach to POCUS management (which will be just as bad as any recipe-based medicine) as opposed to physiological understanding of what is going on with the patient.

There’s so much good information packed in scanning the IVC (properly, in both axes – for more, see a bunch of my previous posts), and frankly, volume responsiveness is the least of my concerns, that it is a shame to toss out the proverbial baby with the bathwater.

So I talked about this at Stowe EM – an awesome conference run by my friend Peter Weimersheimer (@VTEMsono), which I highly recommend to anyone for next year, great talks, people and spot:

Here are my slides:

IVC Stowe

And the audio:

 

Love to hear your thoughts!

Oh yes, and anyone looking to explore physiological, evidence-based, cutting- and bleeding-edge approaches to resus, don’t miss H&R2019 this May in Montreal!

cheers

 

Philippe

Another POCUS HPVG case… Critical…or not? #FOAMed, #FOAMcc

So a couple years ago I posted a discussion about HPVG around an interesting case, noting how, although traditionally felt to give a poor prognosis, this was extrapolated from early data when it was being detected by conventional radiographs. This simple fact, due to the relatively low sensitivity of radiographs for air in the portal system, meant that these cases had a lot of air, implying a worse underlying process that that detected by POCUS, which is exquisitely sensitive to the detection of air bubbles.

Had another interesting case today which I tweeted. This is an elderly patient, POD#3 for a subtotal colectomy for an obstruction, in the ICU with severe AKI. When scanning his RUQ for fluid tolerance assessment, here is what I see:

Impressive. Frank bubbles coming up the PV, and the liver parenchyma with extensive HPVG. He had some abdominal pain, but he was not in shock (at least not pressor or lactic acidosis shock). My first reflex, since he was in AKI (non pre-renal and non obstructive, and with new evidence of loss of integrity of the bowel mucosa, was to get the surgeons to go take a look.

We agreed to scan first and take it from there. Their view was that, given the absence of frank shock, they were not keen to go back in. I have to say I would have preferred that they did go take a look straightaway, but, as they pointed out, opening someone up is not entirely without drawbacks.

So the scan was equivocal, with some air noted in the mesenteric vessels and possible in the mucosa of a bowel loop. Clinically he had not deteriorated. In the meantime, we had stopped his early enteral feeds and put his NGT on suction.

So I took another POCUS look, figuring that if things looked worse, I might take another charge at the surgical team:

Lo and behold, things had resolved… Biochemically, not much change either, and hemodynamics still fine.

So clearly, at least today, the decision to not operate was the right one. Kudos to the surgical team. And it was a more risky decision than that to operate, since the consequences of missing something correctable are worse than those of an unnecessary “white” exploratory laparotomy…

So what did happen? In all likelihood, the post-op ileus on an ill bowel resulted in some dilation and “mucosal leak.”  The NG suction likely decompressed the bowel and allowed the circulation to clear the HPVG.

So the lesson for all POCUS users is that we are using a highly sensitive tool for HPVG, such that this finding is certainly more common than commonly thought, and should be concerning but not necessarily ominous or requiring surgical intervention. Certainly close monitoring and repeat assessments, clinical, POCUS and biochemical are important.

The challenge will be discerning the cases that do need intervention, which is not simple, since waiting for shock or hemodynamic instability would represent a late intervention, likely with poorer outcomes – surgery on vasopressors is a bit suboptimal.

Love to hear comments and others’ experience!

 

cheers

 

Philippe

The Andromeda-SHOCK trial with Korbin Haycock and the Nuclear Bomb Approach to Sepsis. #FOAMed, #FOAMer, #FOAMcc

So managed to pin another really bright guy down today and get his thoughts. Of course we digress some, but I think in all the topics that are truly important to sepsis resuscitation.

 

 

So I think all the resuscitationists I have spoken to tend to hover around the same common points:

  1. lactate is a marker of severity of insult/injury/inflammation but NOT something to specifically treat with an automatic fluid “chaser.”
  2. getting a global assessment of the patient’s perfusion – including things such as CRT is important.
  3. a strategy that seeks to exterminate fluid responsiveness is non-sensical and pathological.

The nice thing for our southern neighbours is that this study may give you a solid excuse to shake off that lactate mandate.

And I think that Korbin’s ending remarks are important, and it is something I try to teach residents, that there is little value in rapidly normalizing hemodynamic values – which treats the medical team very well – if there is an aftermath that is not beneficial for the patient. Kathryn Maitland’s FEAST study is the real groundbreaker for that concept. So probably a coordinated and careful ground assault is better than dropping the nuke.

 For more discussion on this trial check out Rory Spiegel’s breakdown at https://emcrit.org/emnerd/em-nerd-the-case-of-the-deceitful-lantern/ and our discussion at https://thinkingcriticalcare.com/2019/02/19/the-andromeda-shock-study-a-physiological-breakdown-with-rory-spiegel-emnerd-foamed-foamcc-foamer/

cheers!

 

a couple points:

First, much thanks to Scott Weingart whose technical pointers are improving my audio quality! Still a ways to go but on the path!

Second, if you’re not registered for H&R2019, there’s only about 20 spots left. And only a handful for the much-anticipated Resuscitative TEE course. Don’t miss out. If you enjoy these discussions, there will be plenty of that, especially in the protected meet-the-faculty times.

And finally, though he doesn’t yet have a blog, you can now follow Korbin on twitter @khaycock2!

 

Philippe

 

The Andromeda-SHOCK study. A physiological breakdown with Rory Spiegel (@EMnerd). #FOAMed, #FOAMcc, #FOAMer

So recently published was the Andromeda SHOCK trial (jama_hernndez_2019_oi_190001) in JAMA this month.

Definitely interesting stuff, and have to commend the authors on a complex resuscitation strategy that had some real-world flexibility built in in terms of later generalizability and applicability for real-world cases. However there are some fundamentals I have concerns about. Let’s see what Rory thinks:

Yeah. I think the bottom line of opening resuscitationists’ eyes to NOT apply monosynaptic reflexes of giving fluids to elevated lactate is good. In that sense, definitely a step forward.

However, the insistence on maximizing CO under the illusion of optimizing perfusion remains problematic and leads to a congested state unless only a small or perhaps moderate amount of fluid is required to achieve non-volume responsiveness. I think it’s important to realize that the most rapid correction of hemodynamics is a surrogate marker and has not been definitively associated with survival across the board (eg the FEAST study and others), and it’s only proven clinical impact may be on health care workers’ level of anxiety.

Tune in soon for some other smart docs’ take on this!

 

cheers

 

Philippe

 

oh yes and don’t forget The Hospitalist & The Resuscitationist 2019:

 

Is POCUS the new PAC??? A Chat with Jon-Emile Kenny (@heart_lung) #FOAMed, #FOAMcc

So here is what Jon tweeted a couple weeks ago:

Yikes! Does that spell doom for POCUS???

So clearly we had to get to the bottom of this statement…So a google hangout was in order.

 

Part 1 my intro:

and Part 2 our discussion:

 

So the bottom line is that we agree that there is a risk that POCUS may partly head the way of the PAC, or at least be challenged in a similar fashion. Hopefully the wiser physicians will see the inherently flawed logic that would push the field in that direction. Alternately, we could all get our minds and efforts together and try to do a triangulation of data to really pinpoint hemodynamics.

Love to hear comments!

For more of Jon’s physiology awesomeness, visit http://www.heart-lung.org.

Cheers

 

Philippe

 

 

PS for cutting-edge and bleeding edge discussions, including Jon-Emile and a lot more, don’t miss H&R2019 this may in Montreal…

Nerve Blocks for the ICU docs. #FOAMed, #FOAMcc

So despite a long history of POCUSing, I’ve yet to do a nerve block. Working in the ICU, it’s not a routine thing. But a couple times I’ve felt I should be able to do a block for chest trauma patients with rib fractures, and not have to wait for anasthesia availability and get immediate pain control without narcotic side effects.

So I took the opportunity to corral into a corner Peter Weimersheimer (not an easy task given his past powerlifting history!) during #puertoricoFEST2019 and pick his brains about what could be useful for ICU docs to know, and how I should go about it.

Here it is:

Weimersheimer on nerve blocks for ICU

Love to hear others’ thoughts who do this!

Cheers

Philippe