April 18, 2019

POCUS & Venous Congestion: a #FOAMed Collaborative Chapter.

 

So given the importance of these topics, the number of questions and discussions we’ve had on the twitterverse, and most importantly in the spirit of #FOAMed, here is the chapter from the POCUS book which was co-authored by Rory Spiegel (@EMnerd), Korbin Haycock (@korbinhaycockmd) and myself.

Venous Congestion Chapter

We’re also in there introducing our VEXUS score, and if anyone wants to use/validate it clinically, please do!

Love to hear anyone’s thoughts!

 

PS we’ll all be at H&R2019 and running workshops on venous congestion:

https://www.google.ca/amp/s/thinkingcriticalcare.com/2018/11/04/hr2019-final-programme-register-now-montreal-may-22-24-2019-hr2019/amp/

The rest of the chapters are here on Amazon and the e-version here on iTunes!

 

cheers

 

Philippe

March 20, 2019

TCD in the ED? A discussion with Jeff Scott. #FOAMed #FOAMer #FOAMcc

So a couple weeks ago I had the chance to sit in sunny Florida with Jeff Scott (@jsemccm), an ED-intensivist who runs the ED at Jackson South in Miami as well as rounding in the ICU at Jackson Memorial.

His group recently published an awesome article on TCD that pretty much made me realize I have to up my TCD game to the next level.

Here it is (unfortunately walled…)

And here is our discussion:

So there clearly is more to be done with TCD than I have been doing, and maybe it really has a place in the ED. I don’t work first line in the ED so initial stroke patients I only see if they deteriorate, but the idea of visualizing perfusion – or reperfusion – is really interesting.

So if you want to meet Jeff and have him teach you some POCUS TCD, don’t miss H&R2019 which is just around the corner. There aren’t many spots left! Jeff will be running a TCD workshop along with Rob Chen (@ottawaheartrob) which I’m really looking forward to!

Love to hear from anyone pushing the envelope of TCD (or any POCUS application). I believe we are only scratching the surface of what we can do with POCUS, and much study, based on front-line clinicians taking bold strides ahead to see what can be done.

 

cheers

 

Philippe

 

March 13, 2019

My friend, the IVC. #FOAMed, #FOAMer, #FOAMus, #FOAMcc

So I keep hearing and seeing people bash the IVC. Casually dismissing it with a shrug. “It’s not really good for volume responsiveness, you know…”

All that deserves is an eyeball-rolling emoji. That is, unfortunately, the reaction of docs who are trying to devise a threshold or recipe-based approach to POCUS management (which will be just as bad as any recipe-based medicine) as opposed to physiological understanding of what is going on with the patient.

There’s so much good information packed in scanning the IVC (properly, in both axes – for more, see a bunch of my previous posts), and frankly, volume responsiveness is the least of my concerns, that it is a shame to toss out the proverbial baby with the bathwater.

So I talked about this at Stowe EM – an awesome conference run by my friend Peter Weimersheimer (@VTEMsono), which I highly recommend to anyone for next year, great talks, people and spot:

Here are my slides:

IVC Stowe

And the audio:

 

Love to hear your thoughts!

Oh yes, and anyone looking to explore physiological, evidence-based, cutting- and bleeding-edge approaches to resus, don’t miss H&R2019 this May in Montreal!

cheers

 

Philippe

March 1, 2019

Another POCUS HPVG case… Critical…or not? #FOAMed, #FOAMcc

So a couple years ago I posted a discussion about HPVG around an interesting case, noting how, although traditionally felt to give a poor prognosis, this was extrapolated from early data when it was being detected by conventional radiographs. This simple fact, due to the relatively low sensitivity of radiographs for air in the portal system, meant that these cases had a lot of air, implying a worse underlying process that that detected by POCUS, which is exquisitely sensitive to the detection of air bubbles.

Had another interesting case today which I tweeted. This is an elderly patient, POD#3 for a subtotal colectomy for an obstruction, in the ICU with severe AKI. When scanning his RUQ for fluid tolerance assessment, here is what I see:

Impressive. Frank bubbles coming up the PV, and the liver parenchyma with extensive HPVG. He had some abdominal pain, but he was not in shock (at least not pressor or lactic acidosis shock). My first reflex, since he was in AKI (non pre-renal and non obstructive, and with new evidence of loss of integrity of the bowel mucosa, was to get the surgeons to go take a look.

We agreed to scan first and take it from there. Their view was that, given the absence of frank shock, they were not keen to go back in. I have to say I would have preferred that they did go take a look straightaway, but, as they pointed out, opening someone up is not entirely without drawbacks.

So the scan was equivocal, with some air noted in the mesenteric vessels and possible in the mucosa of a bowel loop. Clinically he had not deteriorated. In the meantime, we had stopped his early enteral feeds and put his NGT on suction.

So I took another POCUS look, figuring that if things looked worse, I might take another charge at the surgical team:

Lo and behold, things had resolved… Biochemically, not much change either, and hemodynamics still fine.

So clearly, at least today, the decision to not operate was the right one. Kudos to the surgical team. And it was a more risky decision than that to operate, since the consequences of missing something correctable are worse than those of an unnecessary “white” exploratory laparotomy…

So what did happen? In all likelihood, the post-op ileus on an ill bowel resulted in some dilation and “mucosal leak.”  The NG suction likely decompressed the bowel and allowed the circulation to clear the HPVG.

So the lesson for all POCUS users is that we are using a highly sensitive tool for HPVG, such that this finding is certainly more common than commonly thought, and should be concerning but not necessarily ominous or requiring surgical intervention. Certainly close monitoring and repeat assessments, clinical, POCUS and biochemical are important.

The challenge will be discerning the cases that do need intervention, which is not simple, since waiting for shock or hemodynamic instability would represent a late intervention, likely with poorer outcomes – surgery on vasopressors is a bit suboptimal.

Love to hear comments and others’ experience!

 

cheers

 

Philippe

February 20, 2019

The Andromeda-SHOCK trial with Korbin Haycock and the Nuclear Bomb Approach to Sepsis. #FOAMed, #FOAMer, #FOAMcc

So managed to pin another really bright guy down today and get his thoughts. Of course we digress some, but I think in all the topics that are truly important to sepsis resuscitation.

 

 

So I think all the resuscitationists I have spoken to tend to hover around the same common points:

  1. lactate is a marker of severity of insult/injury/inflammation but NOT something to specifically treat with an automatic fluid “chaser.”
  2. getting a global assessment of the patient’s perfusion – including things such as CRT is important.
  3. a strategy that seeks to exterminate fluid responsiveness is non-sensical and pathological.

The nice thing for our southern neighbours is that this study may give you a solid excuse to shake off that lactate mandate.

And I think that Korbin’s ending remarks are important, and it is something I try to teach residents, that there is little value in rapidly normalizing hemodynamic values – which treats the medical team very well – if there is an aftermath that is not beneficial for the patient. Kathryn Maitland’s FEAST study is the real groundbreaker for that concept. So probably a coordinated and careful ground assault is better than dropping the nuke.

 For more discussion on this trial check out Rory Spiegel’s breakdown at https://emcrit.org/emnerd/em-nerd-the-case-of-the-deceitful-lantern/ and our discussion at https://thinkingcriticalcare.com/2019/02/19/the-andromeda-shock-study-a-physiological-breakdown-with-rory-spiegel-emnerd-foamed-foamcc-foamer/

cheers!

 

a couple points:

First, much thanks to Scott Weingart whose technical pointers are improving my audio quality! Still a ways to go but on the path!

Second, if you’re not registered for H&R2019, there’s only about 20 spots left. And only a handful for the much-anticipated Resuscitative TEE course. Don’t miss out. If you enjoy these discussions, there will be plenty of that, especially in the protected meet-the-faculty times.

And finally, though he doesn’t yet have a blog, you can now follow Korbin on twitter @khaycock2!

 

Philippe

 

February 19, 2019

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:

 

February 12, 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…

February 9, 2019

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

February 7, 2019

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

ECPR 120 min case

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

 

 

January 26, 2019

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!