The Andromeda-SHOCK study. A physiological breakdown with Rory Spiegel (@EMnerd). #FOAMed, #FOAMcc, #FOAMer

So recently published was the Andromeda SHOCK trial (jama_hernndez_2019_oi_190001) in JAMA this month.

Definitely interesting stuff, and have to commend the authors on a complex resuscitation strategy that had some real-world flexibility built in in terms of later generalizability and applicability for real-world cases. However there are some fundamentals I have concerns about. Let’s see what Rory thinks:

Yeah. I think the bottom line of opening resuscitationists’ eyes to NOT apply monosynaptic reflexes of giving fluids to elevated lactate is good. In that sense, definitely a step forward.

However, the insistence on maximizing CO under the illusion of optimizing perfusion remains problematic and leads to a congested state unless only a small or perhaps moderate amount of fluid is required to achieve non-volume responsiveness. I think it’s important to realize that the most rapid correction of hemodynamics is a surrogate marker and has not been definitively associated with survival across the board (eg the FEAST study and others), and it’s only proven clinical impact may be on health care workers’ level of anxiety.

Tune in soon for some other smart docs’ take on this!

 

cheers

 

Philippe

 

oh yes and don’t forget The Hospitalist & The Resuscitationist 2019:

 

Is POCUS the new PAC??? A Chat with Jon-Emile Kenny (@heart_lung) #FOAMed, #FOAMcc

So here is what Jon tweeted a couple weeks ago:

Yikes! Does that spell doom for POCUS???

So clearly we had to get to the bottom of this statement…So a google hangout was in order.

 

Part 1 my intro:

and Part 2 our discussion:

 

So the bottom line is that we agree that there is a risk that POCUS may partly head the way of the PAC, or at least be challenged in a similar fashion. Hopefully the wiser physicians will see the inherently flawed logic that would push the field in that direction. Alternately, we could all get our minds and efforts together and try to do a triangulation of data to really pinpoint hemodynamics.

Love to hear comments!

For more of Jon’s physiology awesomeness, visit http://www.heart-lung.org.

Cheers

 

Philippe

 

 

PS for cutting-edge and bleeding edge discussions, including Jon-Emile and a lot more, don’t miss H&R2019 this may in Montreal…

Nerve Blocks for the ICU docs. #FOAMed, #FOAMcc

So despite a long history of POCUSing, I’ve yet to do a nerve block. Working in the ICU, it’s not a routine thing. But a couple times I’ve felt I should be able to do a block for chest trauma patients with rib fractures, and not have to wait for anasthesia availability and get immediate pain control without narcotic side effects.

So I took the opportunity to corral into a corner Peter Weimersheimer (not an easy task given his past powerlifting history!) during #puertoricoFEST2019 and pick his brains about what could be useful for ICU docs to know, and how I should go about it.

Here it is:

Weimersheimer on nerve blocks for ICU

Love to hear others’ thoughts who do this!

Cheers

Philippe

The ECMO Project: Lend us a Hand!!!

So I’ve been quite passionate about adding ECPR to our shop for quite a while now, but bureaucratic hospital processes, particularly in Quebec these days, has us bogged down and makes progress slow and painful, despite good intentions. So we need a boost, not only to be able to offer this technology to our patients, but more importantly, to show that it can be done in a community hospital, that all you need is the desire to give your cardiac arrest patients the best chance at neurologically intact survival they can get.

Here’s a little explanation, particularly for the non-medical readers:

That, and of course a pre-determined corridor to a tertiary care center with a cath lab and a compatible ECMO system to yours.

We have the good fortune to be a couple blocks from the Montreal Heart Institute who are interested in collaborating, and we have the desire, skill and motivation to pull this this off.

It’s important for both MDs and non-MDs to understand that this approach would possibly save 50% of the patients that we normally have no hope to save. At the point when we initiate ECMO, these patients have almost no chance with the current means. That is an incredible impact.

But we do need your help. The government isn’t moving fast, and won’t until this is established practice (well Dr. Rola, where else is this being done locally? – same question/answer as when I asked for a 100,000$ ultrasound system for our ICU in 2004: nowhere around here!).

So I figured that if we can raise enough money, and with the help of our awesome Foundation – under the presidency of Mr. Arcobelli, no effort has been spared to raise funds and the quality of care that we offer at Santa Cabrini! So to help them out and to get the ball rolling, we’re setting up our project on chuffed.org, a crowdfunding site which is tied to the Santa Cabrini Hospital Foundation, and every dollar will be specifically earmarked for this and not used for anything else.

My hope is that by the end of 2019, we have an active ECMO unit able to be deployed for cardiac arrest cases in the east end of Montreal, and that in the years following, other community hospitals follow suit. We are a small community hospital, but with a big heart!

We need 250,000$. The device costs about 150,000$, each circuit about 7,000$ and we need to set up some training for the team. That should get us jumpstarted and cover the first 10 patients.

We’re more than happy to field any questions. As a start, the Critical Care & Ultrasound Institute be donating a minimum of 2,000$ (it’s a bit early to be able to commit to more, as we do have to feed the participants and bring the faculty…) from the H&R2019 conference,  , which takes place at Santa Cabrini Hospital from May 21-24, 2019.

I’d like to thank Joe Bellezzo, Zack Shinar and Scott Weingart from the @edecmo project who planted the seed and showed all of us that this could be done.

for those who want to know more:

CHEER Study

http://www.edecmo.org

I would also like to thank Santa Cabrini’s Team 6444  of operators, who are a major driving force behind this effort: Sandy Mormina, Rita Pisanelli and more!

PLEASE HELP AND DONATE AT: http://www.chuffed.org (not active yet, will be linked soon) and please forward this to friends and colleagues. You can also send a cheque labelled “ROLA ECMO Project” in the note part of the cheque (this will ensure that the money cannot be used for anything else) to the following address:

Santa Cabrini Hospital Foundation, 5655 Rue St-Zotique, Montreal, H1T1P7, QC, Canada.

Every dollar gets us a little bit closer!

 

cheers and thank you!

 

Dr. Philippe Rola

Chief of Service, Intensive Care Unit, Santa Cabrini Hospital

 

 

Volume status, CHAISE study and other silly questions. #FOAMed, #FOAMcc, #FOAMer

So I just finished reading the CHAISE study, which compared Parm as a surrogate for Pmsf as a surrogate for “volume status.”

It is a really cool study for anyone who loves physiology, which I definitely do, and there may be some interesting elements that can be clinically used.

But let’s first set the record straight. I do not believe that “volume status” is a medical and especially not a scientific term. It is a vague reference to intravascular fluid and can be interpreted in a lot of different ways, making it essentially useless. There is such a thing as the status of your flight (on time, delayed, cancelled), your reservation (confirmed, cancelled), your postal delivery (returned, delivered, in-transit), etc.  But there are no such clear strata for “volume status.”

So what are the true scientific terms that can be measured? Blood volume. So if we had a bedside radiolabelled substance test that could give us our true blood volume, that could give us a real measure of “volume status.”

On the other hand, that would be of marginal use clinically, in all likelihood.

Why? Because there are only three questions that the savvy clinician is trying to answer, in order of importance:

1. Does my patient need fluid?

2. Is my patient volume tolerant?

3. Is my patient volume responsive?

The answer to the first question is mysterious, outside of the obvious extremes, and in my opinion, anyone who feels they can clearly answer correctly is deluding themselves.

The answer to the second question is complex and multi-factorial and includes echographic findings (venous congestion/hypertension, B lines, effusions, ascites) as well as physical examination findings (tight abdomen, edema) and clinical findings (respiratory failure, intracranial pathology) and more. But this is a critical one, because if the answer is no, then you need some really compelling evidence to even consider trying to answer the third question.

The answer to the third question is, outside of the extremes, a bit of a quagmire of assessments and technology with generally poor evidence, particularly in terms of duration of effect. The most fearsome aspect of this third question is that it is usually the first question asked instead of the last, and thus has the side effect of creating volume-responsiveness terminators who, 500cc shot after 500cc shot end up satisfied that they have blasted responsiveness into oblivion.

But that’s probably bad news for the patient, that they have now pushed into venous congestion or salt-water drowning. Unless, of course, they just look for volume-responsiveness in the same way that bird-watchers do, for the sake of scientific satisfaction, and do no more than look, or maybe snap a picture at most.

So sure, echocardiographic parameters for volume status should be under fire, as all other parameters should. The authors in this paper themselves state two critical assumptions in the Parm/msf logic:

(1) that the fluid stay intravascular in the 10 minutes (ok, I’ll buy that)

and

(2) that the compliance is linear (nope, I don’t buy that, especially not in sick patients on vasopressors – as opposed to the normal cardiopulmonary and hemodynamic patients this study was done on).

Essentially, what should be under fire is the obsession with a measurable variable to assess intravascular volume. Too many factors in play, and the answer is useless clinically anyway.

On the other hand, this study is fascinating in terms of what might be done using dynamic Parm… Maybe individualizing pressor response, unstressed volume recruit-ability?  I’ll let @iceman_ex tell us about that at H&R2019!

So what is important is stop points. And reverse points. And yes, these can be looked at using POCUS, and also CVP, and CVP tracings. And yes, there is good data that venous hypertension is a bad state. And this is what you should be looking at, to make sure you have not pushed your patient into a universally pathological state of non-volume-responsiveness.

Cheers

Philippe

So Kylie (@kyliebaker888) had some comments and questions:

Hi Philippe, I just had to read the article after your blog. Most is a bit above my head (yeah right Kylie)– but I am perplexed by three things that I did understand -perhaps you can help me with….
1. Is P(arm) a useful measure? – it went up in 19 patients and down in 8 patients after a 500ml bolus yet they claim it went up (after statistical repeated measures or something)..if P(arm) is confounded by something else – I think they suggest sympathetic tone – shouldn’t we sort that before we start using P(arm) as a reference test.

I don’t think we can consider it to be a reference at all. I think it is an interesting physiological measure and that it might have some application in phenotyping vascular tone/compliance and possibly helping in vasopressor fine tuning. In my opinion for fluids it adds little to what we have.

2. What do you think of their IVC measure – 0.5cm below junction with RA?

As I do for all IVC diameter measures, I think it is inherently mathematically flawed to try to assess a volume using a diameter. Eyeball the whole IVC. A recent study finally looked at this. 3D IVC assessment and (of course) found it better.

3. What do you think of the fact that E changed, but e prime and E/e prime didn’t….That seems like there may not be enough precision in some of those measurements.

I agree.

I also have another savvy-clinician question to add to yours
Q4: Is my patient leaking?

Excellent!

Thanks!

Fluids and Sepsis Twitter Case #foamed

So this morning I shared a case that I’m looking after on Twitter and got asked a really interesting question. But a bit too much for the 140 characters of Twitter. So here’s the answer!

 

Thanks!

#POCUS IVC Pitfall Twitter Poll & Discussion. #FOAMed, #FOAMer, #FOAMcc

So I ran a couple of twitter polls sets the other day. Here is the first:

(if you want the twitter videos see here)

 

 

and part 2:

And to sum it up:

So I just wanted to illustrate something I keep bringing up, essentially that the entire IVC literature based on the AP diameter measurement is physiologically and mathematically flawed. I think the poll and images above clearly support this: given a short axis view, clinicians clearly have a different opinion (and possibly intervention!) than using only a long axis view.

My take, as I’ve said and will keep saying, is that there is a lot of info in IVC POCUS, and the one I am LEAST concerned with is volume responsiveness, which sadly seems to be everyone’s only focus nowadays when it comes to the IVC.

But here’s some food for thought, some of my clinical applications in 5 seconds of scanning:

initial shock patient: big fixed IVC -> no fluids, hurry and find the downstream problem and correct!

resp failure patient: small IVC -> it’s not a massive PE, keep looking for the cause don’t send for a STAT CT angio!

AKI patient: big IVC look at venous doppler and call for lasix, stop the fluids and albumin that were being mistakenly given!

AKI or shock patient & small IVC: sure , start with some fluids and reassess soon (that means hours not the next day)

 

etc..etc.. there’s more, and “fluid responsiveness” is only in extremes and fairly low on the list for me!

 

cheers

 

Philippe

 

ps if you like physiology, and a physiologico-clinical approach, don’t miss H&R2019!