So we had a blast with the VExUS Course a few weeks ago, it was really great to see how much enthusiasm and actual clinical use it is getting all over the world. Humbled, grateful and certainly feeling like the hard work was worth it to have this impact. So even after the workshop, there was a lot of questions, and some take more than a few lines to dig into, and since one participant, Dr. Rajiv Sinanan, a nephrologist, was so organized in his case questions, including a powerpoint with cases, I thought it was worth sharing. My life being busy and chaotic, I unfortunately had to do this on the way to work, so apologies for the audio and video quality! But I think there are some good pearls in there for those starting to use VExUS out there!
For those of you interested in learning more, we are hoping to soon have the ability to hold an in-person workshop, so we do not yet know when the next VExUS Course will be offered, but the online material is available here, and the cost of the online material + later workshop is the same as the full course. Going thru the material and getting some practice in may also help you by providing you with cases to discuss during the workshop.
While the last few months had quieted down, the last few weeks have seen a serious resurgence in COVID cases, particularly in the southern US and in south and southeast Asia. I cam across several really disturbing posts and tweets across medical SoMe about the lack of ECMO beds and cases of refractory hypoxia.
While TCAV(TM) will not save every COVID ARDS patient, in our experience it helps significantly, ideally from the get-go, but also in rescue after failure of traditional modes.
This is why we decided to add this date – sooner than planned – as it seems it may have clinical impact in the current pandemic.
I offered to share in a #FAOMed fashion the online portion of this course with anyone interested and currently struggling with COVID ARDS, but as a faculty we all feel that it is only a basic introduction, and that two other elements are ideally needed, the workshop (included in this course) and some case mentoring for the first few cases, which we are working on.
Registration fee will be waived for physicians from low-resource settings, please explain this in the email to firstname.lastname@example.org to obtain the registration link. Registration will be stretched to 30 participants in order to maintain a good level of interaction during the workshop.
To register: email hospresusconference@thinkingcriticalcare
So it is with gradual amazement and a great sense of accomplishment that we have witnessed the remarkable interest that our field of acute care has taken in VExUS. This has also been tempered by the humility of experience, as all of us have seen fads come and go, and also because an interventional approach based on VExUS is not yet evidence-based, as the studies remain to be done, some being underway. At the same time, it has been a good 4-5 years that most of those involved in the VExUS papers have been using Doppler-enhanced POCUS assessment of venous congestion. Our pragmatic and empiric experience has solidified in our minds the importance of venous congestion and the pitfalls in being oblivious to it. At the same time, we have some reservations about seeing it be used in a recipe form, with a “VExUS-furosemide reflex” which would NOT be how a bedside physiology tool should be used.
Hence, we decided to put this together, to be much more than a “how-to” – which to us has the risk of giving a tool without good instructions – but to be comprehensive in it scope, to take participants from pathophysiology thru ultrasound assessment and finally potential clinical application.
After the success of The APRV-TCAV(tm) Course, we have decided to follow the blueprint and make this a 6 hour, two part course, with a didactic online portion which participants are asked to complete prior to the live workshop, where we will present and discuss cases and the nuts and bolts of clinical management integrating VExUS to the global clinical assessment, POCUS and otherwise, which is how it should be used.
The idea is to come out of this with a solid understanding of venous congestion, the various means to assess it, and a clinical framework to implement into the management of these patients on a daily basis.
The Pilot Course (virtual): September 21, 2021, 1pm eastern time.
The first one, to work out the kinks, will have a token registration fee and limited to 40 participants. If you are a trainee or from a resource-limited area please let us know, we are reserving some complimentary spots. Registration will open at the end of July, so email email@example.com to be considered for a spot! Please include a short description of your practice to be considered for a spot. We are favouring acute care clinicians with POCUS experience as this is not a basic POCUS skill, and we want participants to be able to start using VExUS following the course.
Due to current travel restrictions and the uncertainty related to quarantine, this event will be virtual. We anticipate that further events will likely be live, and this course will likely be given during BeachResus and H&R2022.
Dr. Korbin Haycock (@khaycock2) – Riveside Health & Loma Linda University, CA, USA.
Dr. Rory Spiegel (@EMNerd) – Washington Medical Center, DC.
Dr. Philippe Rola (@ThinkingCC) – Santa Cabrini Hospital-CIUSSS-EMTL, Montreal, QC.
All three of us were part of the original VExUS study and have continued to expand the literature on the topic. We use POCUS and assess venous congestion on a daily basis. We have all been teaching via #FOAMed and live conferences for several years. We’re looking forward to share our experience with each participant.
So at the last Flipping the Vent course, we had the treat to have guest faculty Dr. Gary Nieman give us a lecture on the basic science and physiology behind the TCAV(TM) method, and it was really fantastic, so I just thought it was worth sharing with everyone.
While no ventilation technique will save every patient with severe lung injury, it is time to forge ahead and take steps towards improving the mortality of ARDS, COVID or otherwise, which has stagnated in the last 15 plus years. While ARMA established that 6 ml/kg was better than 12 ml/kg, it really showed little else. By no means can that data be interpreted as being THE best way to ventilate EACH patient, but only that low VT is better than high VT.
We know that driving pressure correlates with mortality. We know that atelectrauma, more so than volu- or baro-trauma, is the main engine behind VILI. Hence those are the things we should be trying to minimize.
So for me, the first wave (spring 2020 for Montreal) was the early proving grounds for APRV-TCAV in COVID-19 respiratory failure, and now in the second wave, we are fine-tuning the approach. For Rory Spiegel in Washington, the first wave blended smoothly into the second and he has accumulated a ton of COVID APRV TCAV experience. From our experience, steadily growing since last spring, this is the go-to mode for the vast majority of COVID-19 cases requiring mechanical ventilation.
Rory and I have been joined by two other faculty members who are equally passionate about teaching APRV-TCAV, and we will try to get some awesome guest lecturers for each iteration of the course.
BREAKING NEWS! We are incredibly happy to announce that we will have an amazing guest lecturer for this edition of the APRV-TCAV course, Dr. Gary Nieman, one of the architects of the TCAV methods, and he will be joining us to deliver a lecture on the physiology of the TCAV principles!
At H&R Reloaded, Rory presented “Flipping the Vent,” essentially a conceptual intro to APRV-TCAV, and we ran a small group workshop, which we also did at Haney’s ResusX, which were really enjoyable, and it seems the participants really came away with a lot, but also a lot of questions. So we figured we’d put together a more comprehensive course to give participants a solid base to start using this mode of ventilation.
The first course was essentially held for the Mayo Clinic’s anasthesia/critical care fellows and RTs and included a team from Ireland as well as a handful of individual participants, and was a success. Hence we give it another run!
This course will consist of an online portion (3h core material as well as supplementary material) done at each participant’s convenience, and a live workshop (3h) on the day of the course, but we are adding to the online curriculum, and participants will have ongoing access to the additional material for a year following the course. We are strongly suggesting participants go through at least the core material, because without a reasonable understanding of APRV-TCAV, the workshops will be very difficult to follow and benefit from.
The workshop is the really awesome part of this course, and will mainly feature in-depth case discussions and where we get to the nitty-gritty and review decisions along the course of management of APRV ventilation. This is where the understanding of how to adjust your ventilation as your patient progresses thru different phases of illness, how to escalate or progress to weaning, and how to troubleshoot along the way.
We will finish with an examination to make sure that the concepts have really gotten across.
“Coffee or a deep interest in ventilation modes is a must if logging onto this course from Europe – the Q&A piece is in the wee hours! Attending this course as a group helped us gain confidence to try APRV-TCAV in the difficult to ventilate COVID-19 patient (We have Draeger ventilators but had not used the TCAV version of the mode before with the 75% PEF setting in the “additional settings” part of the vent). Dr Rola and Dr Spiegel simplified complex concepts. They got us to trouble-shoot problems. I would recommend this course.” (Dr. Catherine Nix, Anaesthetist-Intensivist)
“Flipping the Vent APRV-TCAV was an excellent introduction to this mode of ventilation, delivered in a practical and useful manner. The rationale is clearly explained at the outset and this is built upon throughout, with discussion around exactly how the ventilator and patient are managed using relevant case scenarios. The expertise of the educators on this course make APRV-TCAV accessible for those unfamiliar with it. I have a better understanding of the practical application of APRV-TCAV having attended this course” Dr Cathal Mac Donncha,Critical Care Fellow.
Registration: due to the rapid sell-out of the last course, we have a long waiting list and we will advise those on it to give them first registration opportunity.
Special Circumstances: we understand that many physicians who may wish to attend and benefit from learning may be in different socio-economic situations, and of registration fee is an issue, please email us at firstname.lastname@example.org, and we will do our best to accommodate you. Drs. Spiegel and Rola put a high value to knowledge translation and sharing of skills and information.
The Waiting List: please email email@example.com and let the team you wish to be on the list know in case some spots open up.
Sponsors: we are always looking for sponsors to provide scholarships to physicians or other health care professionals trying to learn. Please contact us if you are able to sponsor one or more!
Schedule (Online module):
Part One – APRV-TCAV Basics (3h) OnLine Module (participants will receive access link with registration)
While our general ignorance in medicine has long since stopped surprising me, the COVID-19 pandemic has really highlighted how little we truly know and how unequipped we are to face new diseases. However it has also highlighted an unparalleled degree of collaboration and sharing across the world which has undoubtedly saved many lives.
In this discussion, a very smart and determined friend of mine gives us a masterclass on platelet dysfunction in COVID19 and opens many fascinating potential therapeutic approaches. I think that his outside perspective on the disease – he is a gastroenterologist – gave him a fresh and unbiased approach, and I suspect he is onto something.
Since recording this I have had a few more cases where I used ciproheptadine, and must admit there was some apparent benefit. While this cannot be conclusive, I do feel it warrants a trial, given the benign nature of the treatment and the not-so-benign nature of the disease!
So I was really honoured to have been invited to talk about VExUS for the Mayo Clinic’s CC department. In the last year watching the spread of VExUS has been really rewarding because so far, everyone who has incorporated it into their clinical practice has seen the substantial impact it can have. And it is just the beginning, with exciting new studies in the pipeline and papers about to be published.
Anyhow, the invitation to speak “at” (Zoom of course given that this is COVID times) Mayo represents another step in the spread of precision medicine as applied to venous congestion.
Sorry to all for the delay, these last weeks have been busy! But as promised we are sharing some of the highlights of H&R Reloaded’s lectures, and here is one that should raise a few eyebrows. Andre Denault is one of the few clinicians whose research is groundbreaking, highly clinical and pertinent. Definitely not the kind of research that is done just to show research is being done.
So for all the amazing talks that were had at H&R Reloaded, by far the one that should change the landscape of acute care the most was Pendell’s, that had most participants’ and faculty members’ jaws drop. Not mine of course, because I had seen the pdf of the talk and had a chat with Pendell weeks before, which gave me time to pick it up off the floor.
I grew up in the Q vs Non-Q era, then came the STEMI vs NSTEMI.
It’s time to change.
There will be resistance. There will be inertia. But there’s virtually no way to prevent it. Might as well be ahead of the curve than among the last stragglers still insisting that the ST segment is infaillible.
So after chatting a few times, finally got to sit down and discuss Farid’s super interesting theories that certainly seem to tie in many elements of COVID pathology. Just to be clear, this is strictly exploratory and for the purpose of generating discussion and research, and should not form the basis of therapy today, though who knows if it may in the next weeks or days, as several studies are being done around this.