Resuscitation Tracks 02: Hemodynamics w/@iceman_ex #FOAMed, #FOAMcc

So I’m in the process of putting together my resus handbook, and the really good thing about writing something up is that it forces one to beef up the entire mental database and fill in blanks that may sometimes be filled by belief, habit, culture or leaps of faith. So part of my process will involve discussing stuff with the brightest guys I know. Who happen to be pretty bright. So I figured it might be stuff worth sharing!

Here, Segun and I discuss the possible uses of Pmsa, of resuscitation philosophy, and touch on the issue of blood pressure vs perfusion. (please skip to 0:30 – sorry can’t cut out!)

 

Love to hear some additions to our discussion!

Here is the paper I was referring to, with the graph on page 2:

MAP in sepsis review

cheers

 

Philippe

The Right Stuff: An Outline. #FOAMed

So, lets get an idea of what we’ll be going over and some basic ideas and principles. And to put things in perspective, I am tackling this from an MD’s point of view. I am not in the business of making people lose weight, I’m not a personal trainer, I don’t have a healthy recipe book to sell, and I don’t run a lucrative organic farm (not sure those exist). I am doing this because I think it is important to look at medicine and health care from the ground up, and make sure we are doing things right. The steady rise in chronic disease and the epidemic of obesity tells us that clearly, we are not doing so.

The principles that apply to sick humans should also apply to those who are well and wanting to remain so. The idea of optimal nutrition ties in to healing injuries and optimal performance as well.

This is an exceedingly complex field, I do not pretend to have completely understood it, but I have seen a lot of consistent signals in media, literature and among trusted friends and colleagues  in the last years, and mostly in the last months when I have focused a fair bit of my reading of medical literature on the topic. There is something there that is largely being ignored both by the general public and the health care professionals.

So let’s get started…with some ideas, some starting points:

  1. Nutrition as is generally discussed in the developed world, including most medical practice, has very little true scientific basis. It is more historic and cultural-based. It is time to review this.
  2. Certain paradigms need to be challenged and re-thought. In the ICU and in acute care, in the outpatient world and in that of the healthy humans. We are all healthy until we get sick.
  3. In chronic disease, the importance of nutrition and the therapeutic impact is much, much undervalued and under-appreciated, and the truth is that most professionals in the health care system – doctors included – have no more than a rudimentary understanding of nutrition, and the little that was taught to them was, as stated above, shoddy from a scientific standpoint.
  4. Our digestive system and body is so much more complex than we think and know. It isn’t just what goes in and what is used, but the individual’s particular genetic traits, current state of health, his or her microbiome (the billions of microbes in our intestines), and the time and frequency of what goes in.
  5. Physiology is controlled by hormones and neurotransmitters.

 

So first, ditch the whole calorie concept. It is utter nonsense. Indeed, as Jason Fung says, we do not have calorie receptors. Calories are a measure of thermodynamic energy, which we are utterly unable to handle, store, collect, etc. The human body simply does not work that way. There are a lot of calories in wood, but we are unable to extract anything from it at all. We absorb glucose, fructose, fatty acids, amino acids, water, vitamins and minerals. So the calories in-calories out is irrelevant from a physiology standpoint. Can it work for people trying to lose weight? To some degree, as it will likely bring on a state of being more mindful of what one eats. But if you truly want to understand nutrition, you have to look elsewhere.

In the case of metabolic syndrome, which has become the scourge of developed countries, the real evildoer is insulin.

Wait, but isn’t insulin something important? Required to control blood glucose, etc? If you don’t have any or enough, aren’t you diabetic? Yup. All true. For those who develop the metabolic syndrome, a strong driving force is insulin. How? Chronically elevated insulin levels required to control blood glucose levels will have two main effects over time:

  1. increased adipose tissue – insulin is a storage/growth hormone. Turned on by excess glucose, it shifts metabolism towards the synthesis of glycogen (short term energy stores), and when this is maximized, the liver makes fatty acids, in turn taken in by adipocytes (fat cells) and used to synthesize triglycerides. The breakdown of fats is also inhibited by insulin.
  2. a progressive development of insulin resistance. Why is this important? Because over time, this will cause increased serum insulin levels, as the body will need to make more insulin for the same level of blood glucose control.

We can see how this sets up a vicious cycle that ends up in weight gain and, more importantly, the metabolic syndrome… And we all know the far-reaching and myriad of clinical consequences this will have.

 

Love to hear comments and ideas!

 

cheers

 

Philippe

 

 

Next post: understanding the hormonal modes involved in nutrition, and some podcats discussions!

 

 

 

Some interesting stuff by some actually smart people:

https://emcrit.org/pulmcrit/hypocaloric-nutrition-theory-evidence-nuts-and-bolts/

Jason Fung’s The Obesity Code and The Complete Guide to Fasting

Tim Ferriss’s The Four Hour Body

Jason Fung on youtube

 

Working out the Clinical Kinks in Venous Congestion: A Discussion w/Rory & Korbin. #FOAMed, #FOAMcc, #FOAMus

It’s really exciting to be at the outer frontier, trying to figure out some new clinical areas. Now these have all been described, however the ability of clinicians to properly identify certain pathophysiological findings has been limited prior to POCUS. Following the trail being blazed by Dr. Andre Denault, we are also working on expanding the applications, particularly in resuscitation/deresuscitation and CHF/AKI. There are more questions than answers, but that’s exactly why it’s interesting.

So for those unfamiliar with the topic here is a small intro:

And for those following, here is the discussion:

 

Do expect more from us about this. Watch this space. It is practice changing.

 

Additional resources:

Here’s a link to the article referenced during the recording: https://www.ncbi.nlm.nih.gov/pubmed/29573604

Andre and I discussing venous congestion

…if you dig around the blog in the past year there are a bunch more!

 

do share your thoughts!

cheers

 

Philippe

 

The Right Stuff: A New Series on Nutrition. #FOAMed

So here is a little video intro to a new series of posts and discussions I’ll be putting up on the blog in the next weeks and months. And yes, it will tie in to acutely ill patients too…

 

 

So please do leave comments and invite yourself into this discussion.

Remember, you are what you eat. It’s true.

 

cheers

 

Philippe

H&R2018 Keynote Lecture: Re-Defining Sepsis by Lawrence Lynn. #FOAMed, #FOAMcc

Lawrence’s work on sepsis analysis is truly groundbreaking. To put this in perspective, one has to recognize that sepsis is an exceedingly heterogeneous disease that, once upon a time, and for good reasons, an arbitrary definition was formulated. This, however, does not reflect sepsis adequately, and needs to change with observational data, as this has tremendous implications in therapeutics research.

Lawrence’s efforts have resulted in data systems revealing a number of different patterns of sepsis, with clear differences in physiologic effects or responses. This may explain why so many failed therapies for sepsis have occurred. It is entirely plausible that some of these therapies may have effects in some of these phenotypes of sepsis but get lost in the statistical mix.

Love to answer any questions anyone may have, and Lawrence will certainly chime in on the discussion!

cheers

Philippe