Musings with Jon-Emile & Phil: IVC and Volume Status – #FOAMed, #FOAMcc, #FOAMus

So I had the pleasure of having Jon-Emile drop by my house today and meeting him in real life, and we decided to record a few of our discussions.  It was pretty much off the cuff, so do excuse our pauses and mostly my hmmms.   But I do think we covered some interesting topics, and trying to use his phenomenal mastery of physiological principles to explain some clinical scenarios and approaches.

In this first one, we discuss a pet topic we share, which is the IVC assessment.

 

Bottom Line?   I think we both agree that a physiological and integrative assessment of the IVC is key. The simple 3cm below the diaphragm two-point assessment extracted from the rest of the cardiopulmonary and abdominal physiopathology is insufficient and has unfortunately contributed to some of the perceived shortcomings of IVC ultrasound. Sorry, no simple recipe here.

 

cheers

 

Philippe

Bedside Ultrasound Case: Look Left and Right! #FOAMed, #FOAMus

So I get a patient in the ED who had chest pain and a decreased LOC, vomited and got intubated. I see this elderly (88 yrs old) gentleman a couple of hours after presentation, after basic management including some plavix and heparin for a mildly elevated troponin.

Of course, by now you all realize that a rapid CUSE (Critical UltraSound Examination) is what I start with, after an ultrabasic history.

So my first couple of views show a more-or-less normal IVC, and here is the parasternal long axis:

Anything exciting here? Not really, nothing to hang your hat on at a glance.

Ok, so thanks to FOAM, I recently decided to add the right parasternal view to my regular exam, both to look for lung sliding (I admit I sometimes skip this when not specifically looking for pneumothorax) but also to possibly see some right sided pericardial abnormalities, etc… Here is what I see:

Hmm… A large, vascular structure that seems to have two lumens… a flap? Back to the patient exam, and the left toe is upgoing  and seems more flaccid in the left upper extremity…

Lets creep up the vascular path to the neck vessels:

Here, we can clearly see that most of the carotid lumen (lower right) doesn’t have any flow. That’s suboptimal. In fact, only a small crescent of flow between 3 and 6 o’clock is seen.

Here is the CT:

 

So here we can clearly see the dissected ascending aortic aneurysm that extends into the right carotid artery.

Due to advanced age and dismal overall prognosis, support was discontinued after discussion with the family.

I thought this would be a great case to share due to the fact that it could have been an initial bedside diagnosis, but I have to say I consider it fortuitous that I happened to look right, then up – which I easily could not have done. Not that it made any difference in this case, but on the next one, it just might!

 

Thanks FOAM!

 

cheers

 

Philippe

 

 

Students/Residents’ Required Readings for Santa Cabrini ICU Rotation. #FOAMcc, #FOAMed

Welcome to your Santa Cabrini Hospital ICU Rotation!

Congratulations on wanting to further your critical care experience. Whether you are planning to work in critical care, the ER, the OR or the wards, knowledge of critical care will be of immense importance to your patients, from the ability to recognize critical illness early to initiating appropriate therapy to managing ventilation, shock, weaning and procedures, the knowledge and skills will come in handy.

In our ICU you will find two critical cornerstones which are – sadly – not as widespread as they should be:  (1) bedside ultrasound (head to toe, not just the cardiac stuff) as a routine, integral part of daily physical examination and assessment, and (2) integration and understanding of applied physiology to each patient (not just application of protocols).

However, to maximize your learning experience, it will be expected for you to do some reading prior to the beginning of your rotation. If you have some building blocks covered, you’ll be able to learn from us more useful, clinical and experiential information.

1. First, review your basic cardiac and pulmonary physiology. Any textbook will do, and yes, you have learned it before, but probably have not applied it much, and it may need a little dusting.

2. Review your basic inotrope and vasopressor drug pharmacology, so we can discuss the fine points of use rather than which is alpha and which is beta, etc…

3. Here are a few posts from my blog I think you should look at:

Sepsis:     http://wp.me/p1avUV-1w

CVP:        http://wp.me/p1avUV-1y

Fluid:      http://wp.me/p1avUV-1G

Interesting articles:   http://wp.me/p1avUV-1G

Bicarb:     http://wp.me/p1avUV-4W

NS:         http://wp.me/p1avUV-5x

Glycocalyx:    http://wp.me/p1avUV-5S

N=1:     http://wp.me/p1avUV-68

IVC ultrasound:  http://wp.me/p1avUV-8E

4. For the more senior residents, here is an amazing resource by Dr. Jon-Emile Kenny (www.heart-lung.org), a review for critical care boards:

2014 CCM Review Notes

5. Get #FOAMed. As a 21st century physician, you will find that the twitter-based meducation is absolutely fantastic. If you haven’t heard of it, google it and get on board.  Great resources include:

http://www.emcrit.org

http://www.lifeinthefastlane.com

http://www.pulmccm.org

…and many more.

 

Yes, this is quite a bit. Don’t try and do it on the weekend before you start with us. Get a head start if you can. But this will make your rotation with us a truly unique and amazing one.

 

Looking forward to meeting you soon!

Philippe Rola

 

Enteral Fluid Resuscitation? The WHO to the rescue in the ED/ICU? (ORT part 1) #FOAMed, #FOAMcc, #FOAMer

So something has been trotting around my head for a few months, and it actually stems from a small and not-so-proud moment I experienced during a conversation with my wife, while she was still a resident.

She was telling me some of the stories of the day, and how one of her supervisors who had a mixed outpatient and ED practice, always pushed them to use PO fluids, get rid of IVs and get the patients home.  I kind of scoffed, in a sadly typical acute care physician mode, saying how you had to be a bit more aggressive and give them IV fluids to revert their dehydration a bit faster.

Then I caught myself. Hmmm. What exactly am I saying this (con brio) on the basis of. Knowledge, or belief?    I tried to find knowledge but came up woefully short. It seems I’m doing this out of habit, what I’ve seen/learned/believed in the two decades since someone handed me an MD degree. Damn.

So, I do believe in evolution. We have evolved platelets to stop bleeding, fibroblasts and osteoblasts that can fix bones, white cells that go mop up the messes, and all kinds of other good stuff.  One thing we do NOT have is small openings in vascular structures that allow unprocessed, man-made fluids directly into the bloodstream. We make these. We insert tubing into normally sterile environment and infuse a vast number of medications directly into this fragile matrix of cells and organic colloid – with the best of intentions.

In our physiology, however, the ONLY way fluid ever enters the vascular spaces is by diffusion from the outside of the endothelial cell into the lumen, molecule by molecule and ion by ion.

So let me seemingly diverge for a bit…

Screen Shot 2015-02-09 at 12.05.58 PM

Prior to the 1970’s, restricting oral intake was a “cornerstone” therapy of diarrheal illness, due to the pervasive belief that the GI tract needed time to heal and recover before resuming normal function. This was felt to be crucial. Hence, only IV therapy was used (in developed countries), and in the underdeveloped world, the death toll was appalling – especially among children.   In the 40’s, Dr. Darrow of Yale started actually studying the GI tract fluid and electrolyte issue, and advocating oral rehydration with mixed fluids. He was able to bring infant mortality radically down in his practice, but it would take over twenty years before a groups started to formally look at this in the 60’s.  Finally, in the late 70’s, the WHO pushed this out into the field, and the childhood worldwide mortality from acute diarrheal illness dropped by over 70%, from over 5 million deaths a year to a bit over 1 million – at that time.

Oral Rehydration Therapy (ORT) is now felt to be one of the most significant advances in modern medicine. Compared to that impact, all the critical care and cardiology trials are about as significant as a drop in a bucket. We’re not talking about composite end points and subgroup odds ratios of 0.85…

For a great review on this check out The History of Oral Rehydration Therapy by Joshua Nalibow Ruxin (google it).  A great story of science and humanity, good and bad.

So, back to 2015 ED/ICU’s.

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The question now becomes the following: why – in the presence of a functional gut – do I choose to entirely rely on non-physiological IV fluid resuscitation?

I can already hear the roars and the outrage and the cries of heresy.  And heresy is certainly what this is (Heresy is any provocative belief or theory that is strongly at variance with established beliefs or customs – Wikipedia). But that doesn’t make it wrong.

So I would ask everyone – particularly the naysayers, to examine their knowledge and see if they actually have any at all that supports the strong conviction that IV fluids are the way to go in ALL cases (my N=1  principle precludes going for the one-size-fits-all therapeutic approach).

Now everyone agrees that, once patients are better, they should be on feeds with little maintenance fluids. I don’t think many will debate that. So that should be the basis to wonder whether, in the presence of a functional gut, a variable proportion of fluid resuscitation in acute illness should be enteral…

I’ll let everyone digest that.

Comments more than welcome.

More to come in Part 2.

 

 

cheers!

Philippe