“Volume Status” and other meanderings. #FOAMed, #FOAMcc, #FOAMer #POCUS

So the discussions go on about volume status and POCUS, and recently one in particular made me realize that it is important to reframe the way we think about “volume status.” As Segun Olusanya (better known as @iceman_ex) said, “the IVC is not a fuel tank indicator,” and indeed it is not. But even if it was, would that be useful? If somehow, an 18 mm IVC (short axis circular or average of course!) corresponded exactly to a 0.70 ml/kg blood volume, would that be of any use?

No. Of course not.

I get asked this question in consult a lot. So I could be a stickler on principle and answer, whether verbally or in a consult, that the volume status cannot be precisely ascertained using POCUS, and keep walking down the hospital hallway.

But let’s instead reconsider the true clinical question for a moment. What does “volume status” mean when requested by a colleague. The truth is that he or she is likely asking you whether there is a need to give fluid, remove fluid, or stay the course.

Ahhhh. Now POCUS, the IVC and its friends can help. A lot. A lot more that most clinical examinations and chart reviews of weights or ins and outs can. Way more. Why? Because if you are cool, with a normodynamic heart and a small IVC, you are on the low side of volume. Now you may also have a lot of B lines from your pneumonia and the lack of volume tolerance will give your answer to be very careful with fluids. If you are warm and hyperdynamic with a small IVC and totally clear lungs, no elevated ICP and a soft belly, you may just be vasodilated but, if your BP is on the low side, some fluid is a fair go, so long as you follow closely thereafter for fluid stop points. If you have a low urine output, a big IVC, a pulsatile PV and a poor LV, you probably need lasix, no matter how clear your lungs are and even if your creatinine is rising, in fact, especially since it is rising.

The permutations are myriad. But that’s why we have MDs and are supposed to be able to integrate bits and pieces of physiological data to come up with an understanding of our patients. And POCUS gives us an unprecedented bedside view into this physiology.

So if you do have legit POCUS skills, and are able to do a bit more than a long axis M mode of the IVC, then try this instead:

“Sure thing, now tell me a bit about your patient – I imagine you’re debating whether to give some fluids or diurese?”

Forget about volume status in terms of absolutes. Just think of what the clinical question is, and give your colleagues the answers they need.

I think the patients will do a lot better that way.

I’ve already put up a lot of stuff about the IVC here over the years.

cheers

 

Philippe

H&R2019 Lecture Series: GI POCUS with Kylie Baker, #FOAMed, #FOAMus.

Now here is a treat. This is one I am rewatching and taking notes, because it fills some holes in my game. No doubt, my GI POCUS is basic, but now Kylie has me starting to look at layers and patterns.

Anyone in ICU needs to be able to assess the abdomen this way.

So here you go!

 

cheers

 

Philippe

…and for more,

can be found here:

 

H&R2019 The Hospitalist & The Resuscitationist: The Essentials On Demand!

As requested, H&R2019 was recorded, and “The Essentials” is now available on-demand –  CME is currently under processing, so it is currently offered at a temporarily reduced price, until formal accreditation is finalized.

This represents most of the talks originally given in Montreal on May 23rd and 24th, as well as some bonus footage of several workshops as well as some didactic and practical sessions from the pre-congress courses.

Of course, nothing beats being at a conference, especially H&R, whose ethos is not only cutting-edge, but even more so, cutting thru barriers between specialties and between attendees and faculty to take everyone’s game to the next level. But hey, if you couldn’t make it, this is the next best thing.

This second iteration of the coolest conference in Canada brought together a fantastic faculty from all over Canada, the US, Europe and Australia to explore various facets of acute care, from the ED to the wards and the ICU.

Note that this is complimentary for H&R2019 attendees and faculty. If you are, please email hospresusconference@gmail.com to obtain your access code.

         This activity is brought to you by the Cabrini Critical Care Group, and represents 30 key lectures from the annual Hospitalist & Resuscitationist Conference, held at Santa Cabrini Hospital in Montreal, Canada, every spring. Each lecture is approximately 15-20 minutes. There is additional bonus footage from the workshops, the Hospitalist POCUS and Critical Care Procedures courses.

SCIENTIFIC PROGRAMME

Scientific committee:

Dr. Joe Nemeth, MD, CCFP – Emergency Physician

Dr. Carol Zambrana, MD, CCFP – Hospitalist

Dr. Philippe Rola, MD, FRCP – Internal Medicine, Critical Care Physician

Dr. Philippe St-Arnaud, MD, CCFP – Emergency & Critical Care Physician

 

Respiratory failure on the wards – MALLEMAT

At the end of this activity, the participant will be able to recognize and discuss the initial period of respiratory instability using available means including high-flow nasal cannulae and non-invasive positive pressure ventilation.

Phenotyping Cardiac Arrest – SPIEGEL

At the end of this activity, the participant will be able to discuss a new way of approaching cardiac arrest and reframing commonly held beliefs and practices into a more practical and clinical approach.

The Blood Bank and You! AJJAMADA

At the end of this activity, the participant will be able to elaborate the medical management of acute bleeding including the appropriate use of reversal agents and the practical usage of blood products and coagulation factors.

Salvaging the Airway – DUGGAN

At the end of this activity, the participant will be able to approach a respiratory distress caused by an airway problem and explain the different options readily available with their pros and cons.

Advanced POCUS-based management of CHF – ROLA

At the end of this activity, the participant will be able to elaborate on a cutting-edge physiological management of congestive heart failure using bedside ultrasound.

Contrast Induced Nephropathy: 2019 Update – MORRIS

At the end of this activity, the participant will be able to comment on the new literature pertaining to contrast induced nephropathy. The participant will be able to better judge the impact of her/his practice on kidney failure.

A Free Upgrade to your WBC: The NLR! – FARKAS

At the end of this activity, the participant will be able to discuss a different way to look at the white blood cell count which may provide important and overlooked information.

Renal Physiology Demystified: Portal Vein Pulsatility and Hyponatremia – PATEL

At the end of this activity, the participant will be able to integrate venous pressure in renal physiology with practical diagnostic and therapeutic applications.

Life-Threatened Asthmatic – MALLEMAT

At the end of this activity, the participant will be able to recognize the key clinical points of the critically ill asthmatic patient.                                         

The Great EPI debate – SPIEGEL

At the end of this activity, the participant will be able to judge the facts and controversy surrounding the use of epinephrine in cardiac arrest and its impact on survival and neurological outcomes.

Revisiting CPR physiology: What do we know? – TERAN

At the end of this activity, the participant will be able to illustrate the key elements of CPR functioning, including from the standpoint of TEE-obtained intra-arrest data.

pH-guided fluid resuscitation – FARKAS

At the end of this activity, the participant will be able to discuss a tailored-therapy approach to fluid resuscitation and assess the key importance of timing of proper fluids.

Intra-Arrest Hemodynamics: One Size Doesn’t Fit All – TERAN

At the end of this activity, the participant will be able to elaborate on how intra-arrest TEE may help optimize and individualize management of resuscitation.

EKG Pearls – MULLIE

At the end of this activity, the participant will be able to recognize a number of subtle but important “don’t miss” findings in the EKG that can have serious clinical consequences.

Perioperative basics – KAUD

At the end of this activity, the participant will be able to manage the pre- and post-op patient through an organized approach.

Classic Cases with a Twist – SKINNER

At the end of this activity, the participant will be able to identify important and frequent dermatology challenges and will be able to include the concept of skin microbiome to their current practice.

The Art of the Bougie – SPIEGEL

At the end of this activity, the participant will be able to elaborate on the technical pearls, the advantages and the reason to use the bougie in airway management.

Appendicitis Audit from the coal face – BAKER

At the end of this activity, the participant will be able to interpret ultrasound images of appendicitis and recognize the pitfalls in their interpretation.

Diastology for Intensivists – CHEN

At the end of this activity, the participant will be able to elaborate on POCUS diastology and to justify its utility in hemodynamic assessment in the care of the acutely ill patient.

Acid-Base in 3 Parts – SPIEGEL

At the end of this activity, the participant will be able to use a practical and physiological approach to acid-base disorders.

The IVC don’t Lie: Ask the Right Question! – KENNY

At the end of this activity, the participant will be able to oppose the physiology of the IVC to its surroundings and reframe many of the common cognitive pitfalls and common clinical approaches.

Blood Pressure: a Closer Look – MAGDER

At the end of this activity, the participant will be able to define the mechanisms behind the generation of blood pressure and the clinical caveats that are key for resuscitationists to understand.

Gut POCUS – BAKER

At the end of this activity, the participant will be able to identify the findings in GI POCUS and comment on the evidence behind it.

Renal Doppler – HAYCOCK

At the end of this activity, the participant will understand the principles and hemodynamics behind doppler interrogation of renal vasculature and how this may be implemented in clinical practice.

Massive Transfusion – WEIMERSHEIMER

At the end of this activity, the participant will be able to discuss the evolution of massive transfusion protocols, and be able to justify the most recent approach.

To REBOA or Not To REBOA – HAYCOCK

At the end of this activity, the participant will be able to assess the indications for the use of the REBOA device in haemorrhage control and identify the complications associated with it.

Traumatic Cardiac Arrest: How To Avoid Killing the Dead! – NEMETH

At the end of this activity, the participant will be able to oppose the critical differences between medical and traumatic arrest and will recognize the pitfalls of managing the latter.

Inhalation Therapy for acute RV Failure – DENAULT

At the end of this activity, the participant will be able to discuss the advanced therapeutics of right sided failure in the critically ill patients and identify the techniques to diagnose and monitor RV dysfunction.

Pmsa: Is There a Clinical Use? – OLUSANYA

At the end of this activity, the participant will be able to discuss the concept of Pmsa and recognize situations where it can have a direct impact.

Insights on Delirium Using POCUS – DENAULT

At the end of this activity, the participant will be able to comment on the POCUS in relation to the development of delirium.

 

BONUS WORKSHOP & COURSE VIDEOS – this bonus section brings you into some of the workshops of H&R2019, and while watching is no substitute for hands-on practice, these clips are packed with clinical pearls only seasoned veterans can share, and make for a great review prior to doing these procedures as well as teaching them to colleagues and trainees. Due to the organic nature of the workshops, we were not always able to catch the very beginning of each discussion, so we do apologize if you feel like you’re just “jumping in,” but it’s better than missing out! In certain workshops, the audio quality is imperfect due to hearing other groups as well, but again we felt there is valuable learning nonetheless. These reasons are why this is a bonus section.

Lung Ultrasound – OLUSANYA & SPIEGEL

Renal Doppler  – HAYCOCK

Micropuncture kits and Midline Catheters  – SPIEGEL

REBOA – HAYCOCK

Art of the Bougie – SPIEGEL

Hepatic and Portal Venous Doppler – DENAULT

Trans-Cranial Doppler – CHEN & SCOTT

 

…and the bonus section may keep growing as we work on cleaning up audio as much as possible.

 

Please click here for more information and to purchase H&R2019 On Demand:

 

 

And don’t forget to join us next year:

 

H&R2019 Lecture Series: pH-Guided Fluid Resuscitation by Farkas! #FOAMed, #FOAMcc, #FOAMer

So I was totally sold on this concept by Josh a couple of years ago and have been using it regularly. Why? Because it makes plenty of physiological sence and frankly, what is being commonly done makes a lot less. Evidence? Weak, but consistent evidence across the balanced vs chloride-rich and thrown in the BICAr-ICU and its enough for me to feel good about it until something even better comes along. Not missing that initial opportunity is the key. But let me let Josh convince you!

 

 

Josh has an IBCC chapter on this here:

https://emcrit.org/pulmcrit/fluid/

Make sure to read it!

Hope you enjoyed!

and for more…

can be found here!

 

Philippe

H&R2019 Talks & Slides!!! #FOAMed, #FOAMcc, #FOAMer, #Hrmed19

 

So please bookmark this page as it will be updated as the talks are released and presentation slide sets are uploaded.

And don’t forget to mark your calendars for next year! Gets better and better!

Slides:

AJJAMADA – Blood Bank PDF

CHEN – CNS POCUS one pager

BAKER – GITH&Rshort

BAKER – Appx4H&Rshort

SPIEGEL – H+R2019-Epi in CA

SPIEGEL – H+R-Phenotypes of Cardiac Arrest

SPIEGEL – H+R 2019-Science of a Bougie

SPIEGEL – Acid-Base-1

PATEL – portalveinhyponatremiafinal

MULLIE – 10 EKG cases

MORRIS – Contrastnephropathy 2019

KENNY – HandR-2019-IVC

HAYCOCK – Thoracic Trauma for H&R

HAYCOCK – Renal Doppler in Acute Care

HAYCOCK – REBOA for H&R

CHEN – Diastology and acute care III

H&R2019 Lecture Series: Mallemat on NIV! #FOAMed, #FOAMcc, #FOAMim

So H&R was a blast again this year. In the spirit of #FOAMed, the lectures will be released regularly.

There possibly will be a full conference on-demand option with CME.

In this opening lecture, Haney masterfully goes through an ABC for non invasive ventilation, sharing some great tips for novice and experienced clinicians alike.

 

for more:

can be found here!

 

and save the dates for next year:

A ResusTEE case discussion with ED doc Serge Keverian. #FOAMed, #FOAMcc

So I’m really stoked about this story. Truly makes meducation worthwhile. While preparing H&R2019, I was chatting with Felipe Teran who suggested he could bring the ResuscitativeTEE course up, which I thought would be awesome. So we did, and got a bunch of local and international participants. Now to me this was part of exposing local ED docs to advanced resus, as we had recently started an Advanced Resus Committee at our shop, all in the line of upping the game and hopefully heading towards eCPR.

So some guys from another local community hospital also took the course and were pretty amped about it and wanted to pick our brains about the practical aspects of resusTEE, as we’ve got a bunch of cases under our belts at Santa Cabrini in the last couple of years.

Well, lo and behold, just days after the conference, these guys used resusTEE with awesome results!

Here is our discussion:

Resus TEE w Serge K

So we need to thank @FteranMD and the @resucitativeTEE team, Mae West, Laura Duggan, Tom Jelic and our own Philippe St-Arnaud for putting together a course solid enough that it had an immediate effect on the participants’ practice and on clinical outcomes.

It is also interesting because of all the political BS that takes place in a health care system, one of the common themes is the desire by some individuals and policies to “hog” the resources and want to centralize everything in so-called centres of excellence. There is, of course, some sense to this – concentrating the clinical experience (eg if you are only doing one central line or one heart transplant a year, you probably shouldn’t be doing any. This, to me, applies for many types of interventions or resources, especially those that are  not exceedingly time-sensitive, where the patients do have the time to get to the well-heeled service or doc that grows the elite expertise, no mater the field.

However, there are a lot of cases where the situation is critical and the patient lands in the closest ED, and the guys and gals in the trenches have to handle it. In my opinion, if these teams are motivated and willing to gain the skills, they need to be supported and equipped. This case is a great example of ED docs in a community hospital integrating an advanced resuscitation technique that is done in only a handful of centres, and in most cases, not yet being done in most tertiary/academic care centres, and doing so with great effect.

Same applies to techniques such as REBOA. We ran a workshop at H&R2019 using the REBOA simulator. It isn’t rocket science. If you’ve put in femoral art lines, let alone PA catheters, this is an exceedingly simple technique. It isn’t just the downtown academic centres that should be using resuscitative technology or procedures. Those patients living in the suburbs who arrest or get smashed may not have the time to make it to those EDs, and they pay the same taxes (in Canada) that keep the system going.

So if anyone reading this is involved even loosely in policy-making, whether institutional or broader, stop this childish nonsense. Let’s get everyone the care they need.

 

 

cheers

 

Philippe