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:
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.
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:
lactate is a marker of severity of insult/injury/inflammation but NOT something to specifically treat with an automatic fluid “chaser.”
getting a global assessment of the patient’s perfusion – including things such as CRT is important.
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.
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!
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!
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.
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.
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.
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