Exploring the Pulmonary Vasculature with Korbin Haycock: RVOT Doppler. #FOAMed, #FOAMcc, #POCUS

So some recent twitter discussions, particularly involving my friend Korbin (@khaycock2) and Lars (@LMSaxhaug) – whom I am trying to get on the podcast soon – were really fascinating in regards to RV and pulmonary hypertension assessment. So time to dig into this a little.
The basic POCUS RV assessment is RV:LV ratio and TAPSE, along with RV free wall thickness (should be below 5mm) and the D sign in parasternal SAX. This is a solid start to screen for significant RV dysfunction.
The next level should be to measure PAP using TR Vmax, in order to assess the degree of pulmonary hypertension. Thats pretty much where I’ve been at for the last few years and wasn’t sure there was really a lot more that was necessary from an acute care standpoint where your immediate questions are fluids/pressors/inotropes and some inhalational pulmonary dilators. I wasn’t convinced I needed more.
But of course Korbin and Lars are on another level, and started to talk about doing RVOT doppler and looking at TR Vmax to RVOT VTI ratios to estimate pulmonary vascular resistance. Is there any difference there? Is my PAP not enough? Well, turns out there may be some useful information there, so I will let Korbin do the talking, and my apologies for my dumb questions during this discussion!
So I will be toying with RVOT doppler and trying to see if this is something that warrants a place in acute care management. I suspect it may be something that may tip towards earlier inhaled vasodilator therapy, or else make not using them a more confident choice. I do like the waveform analysis. I think we generally overlook a lot of good info by focusing on numbers over morphology!
So far, images using the PS SAX view have been quite good:
Additionally, RVOT notching could be suggestive of an acute PE – makes sense (study link here!)
Here are a couple of excellent references:
So thanks to Korbin and Lars for forcing me to up my doppler game some more!
cheers
Philippe
Formula Fun:
Tricuspid regurgitation pressure gradient for sPAP:
sPAP=4*(TRvelocity^2) + RAP or
sPAP=TRpg +RAP
mPAP=(sPAP)*0.61 + 1.9
Acceleration time equations for sPAP and mPAP:
sPAPlog= -0.004(AT) + 2.1
mPAP=90 – (0.62*AT)
Pulmonary Regurgitation pressure gradient:
mPAP=4*(Peak initial velocity^2) +RAP
dPAP=4*(End velocity^2) + RAP
dPAP-PCWP should be about <6mmHg or else PVR is likely, see PCWP equations below
PVR equation to screen for increased PVR, or if PVR < 3 WU:
PVR=10*(TRvelocity/RVOT VTI) + 0.16. TR velocity is in m/sec, if <2 WU, no increased PVR.  This equation is accurate up to 3 WU
PVR equations for increased PVR > 3 WU.  These equations less accurate if PVR < 3 WU:
PVR=5.19*(TRvelocity^2) – 0.4, or more simplified: 5 * (TRvelocity^2). Note that the 5 * (TRvelocity^2 is almost sPAP equation (4 * TRvelocity^2)=sPAP
PVR=sPAP/RVOT VTI if no RVOT notch present
PVR=(sPAP/RVOT VTI) + 3 if RVOT notch is present
PCWP equations (for detection of group 2 pHTN to elevated sPAP), as you know, this is a whole other area, and gets a quite a bit more complicated, but to summarize:
PCWP likely elevated if E/e’>15, unlikely if E/e'<8
In NSR, PCWP=1.24 * (E/lateral e’) + 1.9
In ST, PCWP=1.5 * (E/lateral e’) + 1.5
In atrial fibrillation averaged over 5 beats, PCWP=0.8 * (E/lateral e’) +6
Using color M-mode and propagation velocity: PCWP=5.27 * (E/Vp) + 4.6

H&R2019 Lecture Series: Salvage the Airway! by Laura Duggan. #FOAMed, #FOAMcc, #FOAMer

So here is an awesome lecture by Laura Duggan (@drlauraduggan) on early airway management.

Enjoy!

 

 

 

…and for more lectures full of clinical pearls, (including Laura Duggan’s Workshop!) the Essentials of H&R2019 On Demand are available here:

https://wp.me/p1avUV-zQ

 

cheers

 

Philippe

A Synopsis on Fluid Resus Parameters. #FOAMed, #FOAMcc, #POCUS

Hi, so my good friend Jeff Scott, ED/ICU doc and serious POCUSologist, asked me to summarize our current approach to fluid management, which is an amalgam of literature, physiology and bedside medicine-based evidence.

A few points to emphasize:

  1. does my patient need fluid/ will he/she benefit from fluid.
  2. is my patient fluid tolerant
  3. is my patient fluid responsive – yes, it’s the last and least important

I figure we may follow this up with a discussion – that’s often the best way to get to the real clinical decision points, and it’s always interesting to hear the questions and ideas that come up, so looking forward to it!

I figured might as well make a mini podcast of it, so here it is:

cheers

 

Philippe

“Volume Status” and other meanderings. #FOAMed, #FOAMcc, #FOAMer #POCUS

So the discussions go on about volume status and POCUS, and recently one in particular made me realize that it is important to reframe the way we think about “volume status.” As Segun Olusanya (better known as @iceman_ex) said, “the IVC is not a fuel tank indicator,” and indeed it is not. But even if it was, would that be useful? If somehow, an 18 mm IVC (short axis circular or average of course!) corresponded exactly to a 0.70 ml/kg blood volume, would that be of any use?

No. Of course not.

I get asked this question in consult a lot. So I could be a stickler on principle and answer, whether verbally or in a consult, that the volume status cannot be precisely ascertained using POCUS, and keep walking down the hospital hallway.

But let’s instead reconsider the true clinical question for a moment. What does “volume status” mean when requested by a colleague. The truth is that he or she is likely asking you whether there is a need to give fluid, remove fluid, or stay the course.

Ahhhh. Now POCUS, the IVC and its friends can help. A lot. A lot more that most clinical examinations and chart reviews of weights or ins and outs can. Way more. Why? Because if you are cool, with a normodynamic heart and a small IVC, you are on the low side of volume. Now you may also have a lot of B lines from your pneumonia and the lack of volume tolerance will give your answer to be very careful with fluids. If you are warm and hyperdynamic with a small IVC and totally clear lungs, no elevated ICP and a soft belly, you may just be vasodilated but, if your BP is on the low side, some fluid is a fair go, so long as you follow closely thereafter for fluid stop points. If you have a low urine output, a big IVC, a pulsatile PV and a poor LV, you probably need lasix, no matter how clear your lungs are and even if your creatinine is rising, in fact, especially since it is rising.

The permutations are myriad. But that’s why we have MDs and are supposed to be able to integrate bits and pieces of physiological data to come up with an understanding of our patients. And POCUS gives us an unprecedented bedside view into this physiology.

So if you do have legit POCUS skills, and are able to do a bit more than a long axis M mode of the IVC, then try this instead:

“Sure thing, now tell me a bit about your patient – I imagine you’re debating whether to give some fluids or diurese?”

Forget about volume status in terms of absolutes. Just think of what the clinical question is, and give your colleagues the answers they need.

I think the patients will do a lot better that way.

I’ve already put up a lot of stuff about the IVC here over the years.

cheers

 

Philippe

H&R2019 Lecture Series: GI POCUS with Kylie Baker, #FOAMed, #FOAMus.

Now here is a treat. This is one I am rewatching and taking notes, because it fills some holes in my game. No doubt, my GI POCUS is basic, but now Kylie has me starting to look at layers and patterns.

Anyone in ICU needs to be able to assess the abdomen this way.

So here you go!

 

cheers

 

Philippe

…and for more,

can be found here:

 

H&R2019 The Hospitalist & The Resuscitationist: The Essentials On Demand!

As requested, H&R2019 was recorded, and “The Essentials” is now available on-demand –  CME is currently under processing, so it is currently offered at a temporarily reduced price, until formal accreditation is finalized.

This represents most of the talks originally given in Montreal on May 23rd and 24th, as well as some bonus footage of several workshops as well as some didactic and practical sessions from the pre-congress courses.

Of course, nothing beats being at a conference, especially H&R, whose ethos is not only cutting-edge, but even more so, cutting thru barriers between specialties and between attendees and faculty to take everyone’s game to the next level. But hey, if you couldn’t make it, this is the next best thing.

This second iteration of the coolest conference in Canada brought together a fantastic faculty from all over Canada, the US, Europe and Australia to explore various facets of acute care, from the ED to the wards and the ICU.

Note that this is complimentary for H&R2019 attendees and faculty. If you are, please email hospresusconference@gmail.com to obtain your access code.

         This activity is brought to you by the Cabrini Critical Care Group, and represents 30 key lectures from the annual Hospitalist & Resuscitationist Conference, held at Santa Cabrini Hospital in Montreal, Canada, every spring. Each lecture is approximately 15-20 minutes. There is additional bonus footage from the workshops, the Hospitalist POCUS and Critical Care Procedures courses.

SCIENTIFIC PROGRAMME

Scientific committee:

Dr. Carol Zambrana, MD, CCFP – Hospitalist

Dr. Philippe Rola, MD, FRCP – Internal Medicine, Critical Care Physician

Dr. Philippe St-Arnaud, MD, CCFP – Emergency & Critical Care Physician

 

Respiratory failure on the wards – MALLEMAT

At the end of this activity, the participant will be able to recognize and discuss the initial period of respiratory instability using available means including high-flow nasal cannulae and non-invasive positive pressure ventilation.

Phenotyping Cardiac Arrest – SPIEGEL

At the end of this activity, the participant will be able to discuss a new way of approaching cardiac arrest and reframing commonly held beliefs and practices into a more practical and clinical approach.

The Blood Bank and You! AJJAMADA

At the end of this activity, the participant will be able to elaborate the medical management of acute bleeding including the appropriate use of reversal agents and the practical usage of blood products and coagulation factors.

Salvaging the Airway – DUGGAN

At the end of this activity, the participant will be able to approach a respiratory distress caused by an airway problem and explain the different options readily available with their pros and cons.

Advanced POCUS-based management of CHF – ROLA

At the end of this activity, the participant will be able to elaborate on a cutting-edge physiological management of congestive heart failure using bedside ultrasound.

Contrast Induced Nephropathy: 2019 Update – MORRIS

At the end of this activity, the participant will be able to comment on the new literature pertaining to contrast induced nephropathy. The participant will be able to better judge the impact of her/his practice on kidney failure.

A Free Upgrade to your WBC: The NLR! – FARKAS

At the end of this activity, the participant will be able to discuss a different way to look at the white blood cell count which may provide important and overlooked information.

Renal Physiology Demystified: Portal Vein Pulsatility and Hyponatremia – PATEL

At the end of this activity, the participant will be able to integrate venous pressure in renal physiology with practical diagnostic and therapeutic applications.

Life-Threatened Asthmatic – MALLEMAT

At the end of this activity, the participant will be able to recognize the key clinical points of the critically ill asthmatic patient.                                         

The Great EPI debate – SPIEGEL

At the end of this activity, the participant will be able to judge the facts and controversy surrounding the use of epinephrine in cardiac arrest and its impact on survival and neurological outcomes.

Revisiting CPR physiology: What do we know? – TERAN

At the end of this activity, the participant will be able to illustrate the key elements of CPR functioning, including from the standpoint of TEE-obtained intra-arrest data.

pH-guided fluid resuscitation – FARKAS

At the end of this activity, the participant will be able to discuss a tailored-therapy approach to fluid resuscitation and assess the key importance of timing of proper fluids.

Intra-Arrest Hemodynamics: One Size Doesn’t Fit All – TERAN

At the end of this activity, the participant will be able to elaborate on how intra-arrest TEE may help optimize and individualize management of resuscitation.

EKG Pearls – MULLIE

At the end of this activity, the participant will be able to recognize a number of subtle but important “don’t miss” findings in the EKG that can have serious clinical consequences.

Perioperative basics – KAUD

At the end of this activity, the participant will be able to manage the pre- and post-op patient through an organized approach.

Classic Cases with a Twist – SKINNER

At the end of this activity, the participant will be able to identify important and frequent dermatology challenges and will be able to include the concept of skin microbiome to their current practice.

The Art of the Bougie – SPIEGEL

At the end of this activity, the participant will be able to elaborate on the technical pearls, the advantages and the reason to use the bougie in airway management.

Appendicitis Audit from the coal face – BAKER

At the end of this activity, the participant will be able to interpret ultrasound images of appendicitis and recognize the pitfalls in their interpretation.

Diastology for Intensivists – CHEN

At the end of this activity, the participant will be able to elaborate on POCUS diastology and to justify its utility in hemodynamic assessment in the care of the acutely ill patient.

Acid-Base in 3 Parts – SPIEGEL

At the end of this activity, the participant will be able to use a practical and physiological approach to acid-base disorders.

The IVC don’t Lie: Ask the Right Question! – KENNY

At the end of this activity, the participant will be able to oppose the physiology of the IVC to its surroundings and reframe many of the common cognitive pitfalls and common clinical approaches.

Blood Pressure: a Closer Look – MAGDER

At the end of this activity, the participant will be able to define the mechanisms behind the generation of blood pressure and the clinical caveats that are key for resuscitationists to understand.

Gut POCUS – BAKER

At the end of this activity, the participant will be able to identify the findings in GI POCUS and comment on the evidence behind it.

Renal Doppler – HAYCOCK

At the end of this activity, the participant will understand the principles and hemodynamics behind doppler interrogation of renal vasculature and how this may be implemented in clinical practice.

Massive Transfusion – WEIMERSHEIMER

At the end of this activity, the participant will be able to discuss the evolution of massive transfusion protocols, and be able to justify the most recent approach.

To REBOA or Not To REBOA – HAYCOCK

At the end of this activity, the participant will be able to assess the indications for the use of the REBOA device in haemorrhage control and identify the complications associated with it.

Traumatic Cardiac Arrest: How To Avoid Killing the Dead! – NEMETH

At the end of this activity, the participant will be able to oppose the critical differences between medical and traumatic arrest and will recognize the pitfalls of managing the latter.

Inhalation Therapy for acute RV Failure – DENAULT

At the end of this activity, the participant will be able to discuss the advanced therapeutics of right sided failure in the critically ill patients and identify the techniques to diagnose and monitor RV dysfunction.

Pmsa: Is There a Clinical Use? – OLUSANYA

At the end of this activity, the participant will be able to discuss the concept of Pmsa and recognize situations where it can have a direct impact.

Insights on Delirium Using POCUS – DENAULT

At the end of this activity, the participant will be able to comment on the POCUS in relation to the development of delirium.

 

BONUS WORKSHOP & COURSE VIDEOS – this bonus section brings you into some of the workshops of H&R2019, and while watching is no substitute for hands-on practice, these clips are packed with clinical pearls only seasoned veterans can share, and make for a great review prior to doing these procedures as well as teaching them to colleagues and trainees. Due to the organic nature of the workshops, we were not always able to catch the very beginning of each discussion, so we do apologize if you feel like you’re just “jumping in,” but it’s better than missing out! In certain workshops, the audio quality is imperfect due to hearing other groups as well, but again we felt there is valuable learning nonetheless. These reasons are why this is a bonus section.

Lung Ultrasound – OLUSANYA & SPIEGEL

Renal Doppler  – HAYCOCK

Micropuncture kits and Midline Catheters  – SPIEGEL

REBOA – HAYCOCK

Art of the Bougie – SPIEGEL

Hepatic and Portal Venous Doppler – DENAULT

Trans-Cranial Doppler – CHEN & SCOTT

 

…and the bonus section may keep growing as we work on cleaning up audio as much as possible.

 

Please click here for more information and to purchase H&R2019 On Demand:

 

 

And don’t forget to join us next year: