H&R2019 Lecture Series: Felipe Teran on Intra-Arrest Hemodynamics! #FOAMed, #FOAMcc

Here is an awesome lecture by Felipe Teran from this year’s H&R:

 

 

In resus, there is no one size fits all.

 

 

For anyone who missed H&R2019, you can still catch the Essentials!

 

 

But more importantly don’t forget that registration for H&R2020 is now open!

 

cheers!

 

Philippe

The Resus Tracks: Josh Farkas on Sepsis Metabolic Resuscitation and the CITRUS-ALI Study. #FOAMed

 

So metabolic resuscitation is a topic that both Josh (@Pulmcrit) and I are really interested in. We were looking forward to the CITRUS-ALI study. The results, to me, are good. They continue to establish the fact that there are no real side effects, particularly renal, as this was a concern to some (despite the already large data sets – particularly in the Matsuda study), and in an even higher dose than the Marik study.

Of course since the study was not designed to show a mortality benefit, it wouldn’t be clean to tout their results from that angle, but it certainly should be hypothesis-generating (imagine the cheers from the pundits who would certainly have used it in reverse had the mortality been increased instead!!!).  So for me, it changes nothing, because – if my institution hadn’t decreed (for no legitimate reason I can see) that I cannot use it in patients that I feel would benefit – I would still use it as an adjunct to septic shock management.

There are more studies around the corner, and hope they will come out before next may, so that Josh can give us an update for H&R2020 (#Hresus20)!

Here is our chat:

 

cheers

 

Philippe

H&R2019 Lecture Series: Weimersheimer (@VTEMsono) on Massive Transfusion. #FOAMed, #FOAMer

Sorry for the delay, been bogged down in getting H&R2020 off the ground! But here is another goodie from H&R2019, my good friend Peter W. on an ever-important trauma topic.  Enjoy!

Weimersheimer on MT – H&R2019.

 

cheers

 

Philippe

ps for anyone interested, H&R2019 On Demand can be found here!

POCUS Skill: Bedside Percutaneous Cholecystostomy. #FOAMed, #FOAMcc

So one thing we all pretty much agree on is the importance of source control. Biliary sepsis is one of the more common causes of intra-abdominal sepsis, and among those, there is a not insignificant proportion of cases where a percutaneous drainage procedure is indicated, often related to an elevated surgical risk.

This is the case of a 90 year old man with severe aortic stenosis and a perforated cholecystitis with sepsis (AKI, delirium, coagulopathy) admitted to our ICU. Due to the aortic stenosis, surgical mortality was felt to be quite elevated, hence a percutaneous procedure was done.

I am sharing this to make the case that a percutaneous cholecystostomy is not outside the reasonable skill set of a clinician who is both POCUS competent and has solid guided procedural experience (central lines, thoracic or abdominal pigtails, etc) and in my opinion falls into that same category as pericardiocentesis. All the more so for clinicians working in community hospitals without the luxury of a 24/7 IR team, because in many cases, it is simply not reasonable to wait many hours for source control – the fact that the patient may make it alive to the next morning to have a drainage procedure is not relevant, as the ongoing sepsis over several hours may be something he or she does not always recover from in the ensuing days and is not a risk worth taking unless there is no other viable option. In our center the critical care physicians perform this intervention when IR is not available.

Here, an in-plane approach was chosen with a trans-hepatic route in order to avoid potential peritoneal spillage.

POCUS Pearls: 

(1) Always visualize the guidewire inside the intended space.

(2)When dilating, make sure the proximal part of the guidewire within the target area “disappears” ultrasonographically, confirming entry of the dilator. Why? In some cases the wall may give more resistance (particularly an inflammed pericardium) and the dilator may remain outside – cannulation with the catheter will be impossible.

Procedure:

 

POCUS Clips

 

 

 

 

And the nasty stuff:

 

 

 

Some relevant articles:

https://www.ncbi.nlm.nih.gov/pubmed/12040818

https://www.ncbi.nlm.nih.gov/pubmed/29519331

 

Love to hear of others’ experience,

 

cheers

PS if anyone wants a perc chole workshop at H&R2020 , let me know!

 

Philippe

The Resus Tracks – A Chat w/Lars Chapter 1. #FOAMed, #FOAMcc

So for anyone not familiar with Lars (@LMSaxhaug on Medtwitter), if you are into applied resuscitation physiology, this is someone to follow. He seems to be Norway’s answer to Korbin Haycock (@khaycock2).

He is a POCUS researcher and currently a Cardiology/Internal Medicine Trainee, and I hope someone who will help take POCUS to another level. I’ve been meaning to chat with him for a while after some incredible threads on twitter really pushing the applied bedside physiology envelope.

So here is our first discussion, with a few more planned in the near future as we get down to the nitty gritty. But everything does need an intro.

So here is our discussion:

I think Lars makes some excellent points, particularly the need for global hemodynamic assessment, not having a narrow, almost single parameter threshold approach, as well as his point on adaptative tachycardia – though I am not in full agreement about the atrial fibrillation, but most definitely agree that most of the cases in the ICU are secondary, and deciding how much it is contributing to the hemodynamic compromise isn’t always clear.

Looking forward to further discussions, and I smell a panel discussion with Korbin and Jon-Emile on RVOT doppler!

 

cheers

 

Philippe

 

 

 

 

The Hospitalist & The Resuscitationist. Montreal, May 21-22. (R)Evolution. Don’t miss it. #Hresus20

We’re really excited for the third edition of H&R!

Last year was great, all thanks going to our awesome faculty, and this year, we’re planning on taking it yet to another level. We’ve added some new faculty members who’ll be bringing some interesting perspectives, and there will be a pervasive theme across the two days to really get everyone’s understanding and management of the oft-overlooked venous/right side of things, woven in among the other key topics that last year’s attendees and the scientific committee chose. This is a clear evolution in clinical practice that, paired with POCUS, is really a game changer across a wide range of pathologies. Expect to leave from these two days with at least one extra notch on your belt.

The importance of careful fluid resuscitation has been gaining attention in the last years – take for instance the great work being done by Manu Malbrain at IFAD (International Fluid AcaDemy) who just had their symposium. Treating fluids like the drugs that they are should be our goal.

In addition we have picked a number of important topics, with the idea to share knowledge and practical skills at therapeutic decision points, or else to bring attention to bleeding-edge topics that, though not widespread today, hold promise for further fine-tuning of resuscitation. One in particular is the use of the pulmonary artery catheter, whose use, though having fallen out of mainstream favour, persisted in many areas where clinicians were able to properly use this powerful monitoring tool. We feel it is poised to make a comeback among high-level resuscitationists. For some, it may be a matter of refreshing and re-polishing, and for the new generation, a good time to learn.

So, some slight structural adjustments. The Hospitalist angle gets a pre-conference course, focusing on very practical, applied and critically important topics for the ward patients, including a POCUS workshop to get some hands-on work on . Felipe Teran and his team will bring back Resuscitative TEE, and we will add a Resuscitationists’ Toolbox pre-conference in which to learn or practice certain key skills for the high-level resuscitationist, such as REBOA, the PA catheter, surgical airways and more. And yes, the Jiu-Jitsu workshop is back by popular demand!

The two main conference days will be packed full of interesting talks, both by traditional but exceptional academics, as well as many of the top notch #FOAMed educators. The tail end will have some awesome workshops for those who want to add to their skill set.

And, on a first-come, first-served basis, Early Bird Registrants will be able to book some one-on-one time with faculty for hands-on or discussion or skills workshop.

Scientific Committee

Dr. Carol Zambrana

Dr. Philippe St-Arnaud

Dr. Mario Rizzi

Dr. Philippe Rola

Organized by The Critical Care & Ultrasound Institute for the Santa Cabrini Intensive Care Service at the CIUSSS E-MTL.

 

So here is the preliminary programme:

and in pdf: Pamphlet H&R2020

All of this will be in Montreal, Quebec, Canada, most probably Santa Cabrini Hospital, but full details to follow!

Follow the blog and bookmark this page for conference updates!

The lineup so far… and more to come!

See you there!

 

Click Here to register!

 

Philippe