This is what you see on the anterior chest of your patient:
What can you conclude?
scroll below for answers…
The notable findings are:
a. lung sliding – this indicates that there is no pneumothoraxin the area you are scanning.
b. there are B lines – this indicates that there is interstitial edema – this has no etiological information and must be coupled with the rest of the ultrasound and clinical examination to make a diagnosis. It could represent CHF, pneumonia, non-cardiogenic pulmonary edema, or any other interstitial process.
This is my approach to fluid resuscitation – sorry for the lack of precision which, to me, is actually key. It would be against the N=1 principle to give out a recipe…but here’s a way to think about it:
Sorry the last bit cut off – my iphone can only email an 8 minute audio clip! Which I wasn’t aware of until today. Anyway all that was lost at the end was “thanks for listening and I’d really like to hear comments and others’ practices!”
And here’s a disclaimer: I don’t think this is the be-all and end-all. My resuscitation is a work in progress, both in terms of new fluids coming up, and in terms of identifying subgroups or individuals who would benefit from a different approach, so I’m definitely eager to hear from anyone who does things differently – but physiologically!
Please see Dr. John Myburgh’s excellent review on fluid resus in NEJM sep 26th issue!
A 55 year old man admitted to the ICU for sepsis, recovering multi-organ failure with persistent culture-negative fever.
Longitudinal view of the left internal jugular vein.
What do you see?
scroll below for an answer!
Thrombosed internal jugular catheter. This patient was anticoagulated. The fever disappeared within a few days and the thombosis decreased significantly. It is difficult to be certain whether the fever was a cause but examining central lines is part of our fever workup.
Just a quick word to relate an interesting conversation I had with a colleague last evening.
I was taking over an ICU for a night’s coverage and going over the sicker patients with the current daytime attending, my friend and highly esteemed colleague Edgar Hockmann. We were discussing a particularly challenging case of a young (40’s) patient with staph aureus sepsis and MSOF, and trying to come up with some tweaks, and ended up discussing the concept of tailored therapy to each patient’s physiology, which is right up my alley of N=1 thinking.
Now, as background, Edgar is a particularly bright guy who routinely challenges dogma, whether his own or others’, and I always learn from any conversation with him. He has given awesome lectures in our conferences for the past several years. In this case (in addition to some fascinating microcirculation stuff I will have to digest and regurgitate at some point), he gave me a great teaching analogy:
Asking the question “what is the best treatment for disease x?” is essentially analogous to asking “what’s the best size for a suit?”
You can debate it all you want, but ultimately, if you’re a 46 short or a 38 tall, the 42 regular on the store manikin won’t look too good on you.
And so I may be reiterating myself, but it is really key to assemble all the physiological evidence you and (physical exam, ultrasound, laboratory, etc…) and try to determine what this patient needs, not what most patients would need in a similar situation. Fluids in or fluids out? Which type of fluid? Blood pressure goals (MAP of 65 for everyone…really…)? Urine output goals? We’ll try to go over each of these in the next weeks/months.
It’s a lot easier to follow a protocol.
…but my guess is that if you went to Savile Row, I doubt you’d see Shaquille O’Neal and Danny De Vito walking out with the same suit…the haberdashers would be fired…