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.

Here is the link: https://us02web.zoom.us/rec/share/JlAl-vjLYfvDPJife3yMZo48TF0ZaDCyHIqkV2Z7R-vTpnzXREfiOQE477lTdXCg.Vi1XeeT4OI0I1SuE

And the passcode: @GJ$7rBs

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!

Cheers,

Philippe

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.

Here is the video!

Here is the audio only:

Please share if you have interesting information around this, and if you are interested, as you heard, Farid has accepted to join in H&R Reloaded’s Virtual Hangout Room on July 31st evening!

cheers

 

Philippe

 

So I’ve been meaning to fine tune this concept and really start applying and following more rigorously, so I wanted to see what the only clinician I know of doing it at the bedside was doing in a stepwise fashion.

AKI is one of those things that really, really bugs me. It’s common, it’s serious, impacts mortality in the ICU population, and yet to me, it is usually poorly managed by the vast majority of clinicians, usually by examination of surrogate indices and time-lagging imaging with poor specificity and sensitivity for the actual diagnoses you need to rule in or out, which are pre-renal failure and post-renal failure. With a probe in your hand and a decent understanding of physiology, you can rule both of these categories out in about 30 seconds, add a minute for VEXUS and in a grand total of 90 seconds you are left with either a diagnosis or else  the intrinsic AKI category as the last one standing and it’s time to hunt for offenders.

But that’s not what we’re talking about today, but rather, the fine tuning of macro-hemodynamics in relation to your intra-renal micro-hemodynamics. Fascinating stuff.

Video Link Here!

 

Audio Only:

 

Love to hear from anyone trying this!

So you can join us during H&R Reloaded’s Virtual Hangout Room and discuss this and a bunch of other skills or strategies involved in critical care and try to tease out the details from Korbin and the rest of our amazing faculty!

 

Cheers,

 

Philippe

For a little non-COVID #FOAMed, which we still need…

Here’s one that always gets me, that I always try to make sure the residents always understand before they leave our rotation!

I’m pretty sure if you have been fortunate enough to not come across someone doing this, you will – when you do, find a tactful way to share the knowledge!

Oh and don’t forget that H&R Reloaded is on!

cheers

 

Philippe

If you missed it, and want to catch up on some fantastic cutting edge lectures, it is available OnDemand at the following link:

Now available here!

 

So after a lot of discussion, we decided to do this, a blend of the original H&R2020 with the current COVID-19 experience, essentially a look to the next year of critical care management as far as one can figure.

This will take place July 29-30-31 from 1800-2200.

Though WebConferencing can’t quite match the atmosphere of a boutique conference like H&R, we are setting up a virtual Hangout Room so that participants can exchange with the different faculty members in an open session.

 

H&R Reloaded Programme in PDF

June 15th update:

CME Accreditation just in, 12 Cat 1 AMA!

 

July 31st

Click here! Registration is open!

The H&R2020 Team

So just got what I think is an excellent and common question from a reader, worth addressing with a mini-podcast:

Dr Rola, my name is Pedro Alvarado, i’m a Mexican critical care fellow (currently in the 2/2 training year). Been very interested in the last year on being able to answer the question: is my patient going to benefit form fluid administration? (particularly in the case of an objectively diagnosed distributive shock + ARDS, i think by the way, a very difficult to answer question in the majority of Mexican ICU´s).

To answer this question i thought, until recently, one should start by answering if the patient is fluid responsive. The concept of venous congestion and fluid tolerance seems to be the counterbalance that might complete the equaition of benefit/harm ratio of fluid administration on an already high-output state. As it is, i’ve been very interested in what you have recently been describing as the VexUs score. One question, you mention this US tool as a useful stop point for fluid administration in septic (distributive I assume) patients. I understand from your explanation that the further you document ultrasonographic sings of venous hypertension from the RA (hepatic -portal-renal vein), the worse the hypertension and possibly its consequences might be. Also you imply that the earliest you document signs of venous hypertension, the better, so that you can counterbalance benefit/harm ratio of fluid administration as soon as possible.

Understanding that the first, relatively easy measurable macrostructure to be affected by right-sided hypertension is the RA, what makes VExUS more valuable than a good,old CVP monitoring for this purpose? Far more expensive and time consuming, the US is. Also CVP absolute values and trends can be continuously measured.

So here is my answer: