Great lecture exploring the grey zone of high risk intermediate PE. To me a very interesting area. Don’t let anyone tell you there is clear evidence on how to manage these patients – there isn’t. There’s a lot of nuance and we don’t quite yet have a grasp on how to really know who needs more aggressive management. People like Asher and those pushing the envelope with PERT teams and exploring this space will hopefully get us there.
My personal take is that the answers will be in using combined markers of congestion and forward flow (because obstructive shock both congests and restricts CO) along with some (CT?) measures of anticoagulation-responsiveness of clot burden, with dynamic cardiopulmonary reserve measures.
We’re super excited about coming to NYC, but even more about unleashing The VExUS Course 2.0, which will include the integration of venous congestion into our comprehensive hemodynamic interface framework. So participants will have an all-new version of the course, along with an introduction to the interface concept which is gaining a lot of traction, and (of course we are biased) we feel is the way forward in assessing and managing any hemodynamic issue. So this will be 4 hours of hands-on workshop and case discussion. We will also introduce participants to the use of the FlowPatch, a Doppler system for the neck veins that assesses both forward flow and congestion, and fits very well into the interface system. This course is for those who believe (as we do) that tailoring treatment to the individual patient’s pathophysiology is the way forward. Participants will leave having levelled up.
Who Should Attend?: Any clinician looking after sick patients, particularly those involved in resuscitation, congestive heart failure, and kidney injury. Learning Objectives: (1) To understand the pathophysiology behind venous congestion, (2) To be able to analyse venous congestion with bedside ultrasound, both with traditional devices and with the Flosonics FloPatch, (3) To be introduced to the Hemodynamic Interfaces and learn how to incorporate findings of venous Doppler within this framework. Course Format: flipped classroom with 4hr Pre-Course Material and 4h Hands-On Workshop. Cost: $499 Physicians/$399 Trainees. No CME.
So for the last couple of years, originally at the request of my good friend Jay Chatterjee of Riverside, California, we have been putting together a series of hemodynamic lectures, featuring several familiar H&R faculty who really love this topic, for the Riverside and Santa Cabrini critical care fellows. This past year, we basically went thru our interface model (https://pubmed.ncbi.nlm.nih.gov/40423078/), and were joined by a new group of fellows from Aurora St-Luke’s, and this year will welcome fellows from Ben Daxon’s program at Mayo.
These rounds consist of a panel discussion followed by case discussion and encourages – no – requires participation from the fellows. We’ve found that all have taken intuitively to this hemodynamics model particularly when tied to clinical cases to get some reps into the practical use.
So this year, we are planning an 8 session series, 90 minutes each, running from September to June, once a month. Fellows will have some pre-reading to do and several will be requested to present a case with challenging hemodynamics for the panel to discuss.
We would like to give other fellows the opportunity to take advantage of this unique set of discussions, and this year will add one group of fellows, so if you are a program director or involved in critical care fellowship education, reach out to hospresusconference@gmail.com and let us know. It will be first come, first served. The registration fee for a program to attend will be 499$ USD.
Unfortunately, we will not be accepting individual fellows for this as we feel that implementing an interface-based hemodynamics approach will work far better as a team than via individuals.
Everyone is welcome to watch the first iteration of these below:
FACULTY – Jay Chatterjee, Korbin Haycock, Pedro Salinas, Philippe Rola, Rory Spiegel, Ashley Miller, Sara Crager, Jon-Emile Kenny, Matt Siuba…and more.
Thanks and to the fellows, looking forward to meeting you in September for our 2025-26 series!
Here’s a throwback to #HR23 when Andre Denault first introduced the PAC with an RV port to analyze the RV waveform, which we usually only have during initial advancement of the PAC (I confess I have sometimes pulled back just to get it and look at that slope!). But these are now available! As always, invaluable hemodynamics by the grandmaster Andre!
So when we saw this study come out last week, we thought it was worth having a little chat about it, so let’s see what my usual suspects (when it comes to TCAV and, well a lot of other things…) had to say about it, and of course about TCAV in general!
So for anyone who hasn’t yet heard, #HR25 is coming up in a couple of months, and while this year, we are not specifically talking about TCAV, it will be absolutely fantastic, and there is an awesome ventilation pre-congree course, Eduardo Mireles Cabodevila’s SEVA Course, and of course Rory, Korbin and I will be more than happy to hallway talk your ear off about TCAV, so come and hang out!
Of course, for those who really want to deep-dive APRV-TCAV, our Flipping the Vent course is available online, and if you have a group/team, we can organize an online workshop as well.
It was so great to meet, hang out and talk ECPR with Paris’ SAMU ECPR leader Lionel Lamhaut last month in Montreal, a city we are actively trying to bring pre-hospital ECPR to, thanks to the relentless work of Lawrence Leroux.
In the meantime, we are super excited to host the North American Premiere of Lionel’s famous pre-hospital ECMO course and open the registration for a two day, small-group affair with hands on workshops, lectures and discussions with ECPR experts. There are only 20 spots, so don’t wait. Come learn from some of the world leaders including Lionel himself, of course! And we may even have a surprise lab in the works…
So I’m always glad to spend some time chatting with my buddy Korbin, I always learn something! Here we talk about some nonsensical things we’ve seen and heard related to clinicians’ understanding of the hemodynamic circuit. And Korbin begins to introduce the interface 2.5!!! Lets see what develops with that.
Of course, anyone wanting to deepen their understanding and clinical use of hemodynamics and applying interfaces, its what we are focused on for #HR25!!! Join us!
Every resus doc needs to have a holistic approach to shock – MAP and forward flow simply isn’t enough. Here, Matt and I chat a bit about recent things we’ve heard in the world around us, as well as how we use and see the use of the interface concept.
So over the years I’ve learnt invaluable stuff from each and every one of the colleagues I’ve managed to build a network with, and certainly I have learnt – and unlearnt – a lot from this guy. Here, Rory and I discuss the concept of interfaces that a group of us painstakingly crafted over the last year.
So I hope this starts to spark some interest. Recently I’ve heard of a few discussions around sepsis and shock resuscitation that took place at pretty respectable and large conferences, and, to be frank, I was fairly aghast at what was being taught, especially to the young trainees. This type of pure forward-flow/fluid responsiveness obsession with no regard for tissue perfusion, congestion, etc is really distressing to hear… We have a lot of teaching to do.
At our hospital, typical of community hospital intensive care units that do not have an extensive structure of junior and senior trainees who generally staff the university hospitals after hours, medical coverage depends on collaboration between nurses and intensive care doctors as well as their emergency room colleagues. If there is an immediate requirement for a doctor to handle a situation, the emergency room doctor will come right away, and handle things until the ICU on call doctor – who takes call from home – can make it in to take over, which is within 30 minutes.
A typical day for our intensivists consists of rounding on the patients in the ICU as well as handing the consults and procedures that originate from the wards or the emergency department. There are usually two doctors who divide up this work. For the evenings and nights, these two alternate during the week as to who covers emergency situations. However there are many clinical issues which simply reflect ongoing care of acute issues, such that the intensivists generally do evening “rounds” with the charge nurse, going over these issues and resolving whatever can be resolved. According to a recent poll on X (formerly Twitter), among over 400 intensivists who do home call, around 60% had a similar practice of evening or “before bed” telephone rounds.
Our team would often ask the nurses or respiratory therapists to describe curves or features in the vital signs, or at times nurses would like the doctor’s opinion on something about the patient. They then verbally describe as well as possible these findings. While generally excellent, there are inherent limitations to verbal description.
The recent release of the Apple Vision Pro AR/VR headset gave the team an idea for a pilot project: could the use of these on both ends improve the quality of these night rounds? Following a discussion with Mr. Ronald Davidson of our hospital foundation, we decided it was worth giving it a try, given the particularly impressive resolution of these headsets.
How it works: the nurse in the ICU can put on the Vision Pro and proceed to facetime the on-call intensivist, who puts his or her device on at home. The nurse then shares her view, such that the intensivist is now seeing an immersive and ultra-hi resolution view of the ICU, wherever the nurse is looking.
ICU Nurse sharing her view of the monitors using Apple Vision Pro/Infirmiere des soins intensifs partageant sa vue des moniteurs avec le Apple Vision Pro:
ICU On-Call Physician Virtually doing evening rounds / Medecin de garde faisant sa tounee virtuelle de soiree:
Armed with a myriad of additional visual cues, as well as the ability to ask the nurse or respiratory therapist to perform a maneuver or modification to certain parameters, for example on a mechanical ventilator, this makes for, in certain cases, a significant increase in the quality of the discussion and medical decisions taken. This enables the nurse or other health care practitioner to make sure issues and concerns are transmitted in the most reliable way to the on-call intensivist.
What’s Next? Our ICU team at Santa Cabrini always strives to be innovative and at the cutting edge of the care that can be offered to our patients, and has pioneered several medical advances in the last decade. This high level VR open many possible developments for remote medical consultations and assistance, both intra- and inter-hospital, as well as several possible educational application. We are looking forward to seeing what else we will come up with in the next years with this technology!
PS – Because this is part of the public domain, and because doctor-bashing is a popular sport, we feel it is necessary to nip pundits’ enthusiasm in the bud for certain issues. Firstly, during Facetime, recording is disabled in the Apple Vision Pro, as there is no image stockage, so patient confidentiality is at no risk, or at least no more risk than during a phone conversation. Secondly, this in no way decreases the physician presence at the bedside. Our team has a low threshold to come to the hospital and assess patients or do necessary procedures, and this has in no way impacted this aspect. It has, so far, only enhanced the quality of the exchanges.
The biggest thanks for this project goes to the Santa Cabrini Hospital Foundation (www.fondationsantacabrini.org) who have the vision, the drive and the personality to help Santa Cabrini Hospital remain innovative for the benefit of its community!
Dans notre hôpital, typique des unités de soins intensifs des hôpitaux communautaires qui ne disposent pas d’une structure étendue de stagiaires juniors et seniors, généralement présents dans les hôpitaux universitaires après les heures de service, la couverture médicale dépend de la collaboration entre les infirmiers et les médecins des soins intensifs, ainsi que leurs collègues des urgences. S’il y a un besoin immédiat d’un médecin pour gérer une situation, le médecin des urgences interviendra immédiatement et prendra en charge les choses jusqu’à ce que le médecin des soins intensifs de garde – qui est d’astreinte à domicile – puisse arriver, ce qui se fait généralement dans un délai de 30 minutes.
Une journée typique pour nos intensivistes consiste à faire le tour des patients dans l’USI ainsi qu’à gérer les consultations et les procédures qui proviennent des services ou du service des urgences. Il y a généralement deux médecins qui se répartissent ce travail. Pour les soirées et les nuits, ces deux médecins alternent au cours de la semaine pour couvrir les situations d’urgence. Cependant, de nombreux problèmes cliniques reflètent simplement la prise en charge continue de problèmes aigus, de sorte que les intensivistes effectuent généralement des “tours” en soirée avec l’infirmière en chef, abordant ces problèmes et résolvant ce qui peut l’être. Selon un récent sondage sur X (anciennement Twitter), parmi plus de 400 intensivistes qui font des astreintes à domicile, environ 60 % avaient une pratique similaire des tours téléphoniques en soirée ou “avant le coucher”.
Notre équipe demande souvent aux infirmières ou aux thérapeutes respiratoires de décrire les courbes ou les caractéristiques des signes vitaux, ou parfois les infirmières souhaitent connaître l’avis du médecin sur quelque chose concernant le patient. Elles décrivent ensuite verbalement ces constatations du mieux qu’elles le peuvent. Bien que généralement excellentes, ces descriptions verbales présentent des limites inhérentes.
La récente sortie du casque AR/VR Apple Vision Pro a donné à l’équipe une idée pour un projet pilote : l’utilisation de ces dispositifs des deux côtés pourrait-elle améliorer la qualité de ces rondes nocturnes ? Suite à une discussion avec M. Ronald Davidson de notre fondation hospitalière, nous avons décidé qu’il valait la peine d’essayer, compte tenu de la résolution particulièrement impressionnante de ces casques.
Comment cela fonctionne : l’infirmière de l’USI peut enfiler le Vision Pro et procéder à un appel FaceTime avec l’intensiviste de garde, qui met son appareil en marche chez lui. L’infirmière partage alors sa vue, permettant à l’intensiviste de voir une vue immersive et ultra-haute résolution de l’USI, selon l’endroit où l’infirmière regarde.
Infirmière de l’USI partageant sa vue avec l’Apple Vision Pro :
Médecin de garde en soins intensifs effectuant virtuellement des rondes en soirée :
Équipé d’une multitude d’indices visuels supplémentaires, ainsi que de la possibilité de demander à l’infirmière ou au thérapeute respiratoire d’effectuer une manœuvre ou une modification de certains paramètres, par exemple sur un ventilateur mécanique, cela permet, dans certains cas, d’augmenter de manière significative la qualité des discussions et des décisions médicales prises. Cela permet à l’infirmière ou à un autre professionnel de santé de s’assurer que les problèmes et les préoccupations sont transmis de la manière la plus fiable possible à l’intensiviste de garde.
Quelles sont les prochaines étapes ? Notre équipe de l’USI de Santa Cabrini s’efforce toujours d’être innovante et à la pointe des soins offerts à nos patients, et a été pionnière de plusieurs avancées médicales au cours de la dernière décennie. Ce niveau élevé de réalité virtuelle ouvre de nombreuses possibilités de développement pour les consultations et l’assistance médicale à distance, tant intra- qu’inter-hospitalières, ainsi que plusieurs applications éducatives possibles. Nous sommes impatients de voir ce que nous allons encore inventer dans les prochaines années avec cette technologie !
PS – Étant donné que cela fait partie du domaine public, et parce que critiquer les médecins est un sport populaire, nous estimons qu’il est nécessaire de tempérer l’enthousiasme des commentateurs sur certains sujets. Tout d’abord, pendant FaceTime, l’enregistrement est désactivé sur l’Apple Vision Pro, car il n’y a pas de stockage d’image, donc la confidentialité du patient n’est pas en danger, ou en tout cas pas plus qu’au cours d’une conversation téléphonique. Deuxièmement, cela n’enlève en rien la présence du médecin au chevet du patient. Notre équipe a un faible seuil pour se rendre à l’hôpital et évaluer les patients ou réaliser les procédures nécessaires, et cela n’a en rien impacté cet aspect. Cela a, jusqu’à présent, uniquement amélioré la qualité des échanges.
Les plus grands remerciements pour ce projet reviennent à la Fondation de l’hôpital Santa Cabrini (http://www.fondationsantacabrini.org) qui a la vision, la motivation et la personnalité pour aider l’hôpital Santa Cabrini à rester innovant au bénéfice de sa communauté !
thinking critical care 