acute

December 23, 2018

Discussing “ARDS” (and of course fluid management and #POCUS) with @iceman_ex! #FOAMed, #FOAMcc

So sparked by some recent twitter discussions where we were talking about ARDS in a somewhat controversial fashion, I thought it may be worth expanding a bit on the topic.

Essentially my stand is that ARDS is largely an iatrogenic disease mediated by (1) overeager fluid resuscitation of various disease states that fundamentally do not require large amounts of fluids despite commonly held beliefs (sepsis, pancreatitis, etc…) and (2) the absence of frequently used “stop points” of fluid resuscitation with instead a misguided focus on detecting (and intervening upon) volume responsiveness.

In our ICU, true “ARDS” (eg not generated by salt water drowning) is a rarity. Maybe one or two a year, usually a massive primary pulmonary insult.

Anyhow, here, Segun and I discuss this:

 

Ognjen Gajic refers to this article in our discussion.

 

So it seems clear that there is much to discuss. We didn’t even really get into the juice of the stop points. Stay tuned!

 

oh yes… so if these controversial, cutting- and bleeding-edge topics, don’t neglect joining us at H&R2019. Segun and many others will be there!

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

 

 

cheers!

 

 

November 7, 2018

The Subtleties of the SHOC-ED Trial: Don’t Just Read The Abstract! #FOAMed

So this was my comment to my friend Jon’s awesome discussion on the SHOC-ED Trial, which is certainly interesting.

Jon, great post as always! I do agree with most of it, but would have to caution readers about reading it with the filtered glasses that make people too often take home the message that they want to – usually the path of least resistance (or change). I think your main point and most critical one is that there is no protocol or recipe that should ever be applied to resuscitation, especially single-variable-based resuscitation (eg old school orders like CVP>12 lasix and <12 bolus), and substituting the IVC for CVP won’t help. And from a standpoint of volume-responsiveness, I totally agree, with the understanding that as the IVC gets more plethoric, the percentage of responsive patients will decrease, inevitably, but one cannot predict with certainty whether that one patient will or will not. However, the parallel change is that, as the IVC gets more plethoric, the volume tolerance is likely decreasing as well, so that your benefit to risk ratio is dropping. And of course you can’t recipe that just based on IVC, but should be looking at the site of pathology (eg lung, brain abcess, pancreatitis with ACS, etc…), physical exam, to determine your patient’s volume tolerance. Because we all know that most of that miraculous fluid will end up clogging the interstitium, with consequences ranging from cosmetic to fatal (though usually blamed on the patient being “so sick” in the first place, absolving the clinician from any wrongdoing). So comments like the one previous to mine, stating “give volume and see if the response occurs” are, in my mind, a poor approach. We know from studies that you cannot simply remove the fluid you gave and go back to the start with lasix (glycocalyx damage, etc), and we also know that much of the effect of said fluid administration dissipates in minutes to hours (I’m sure Jon can quote these studies off the top of his head!).

As we have discussed in the past, I think POCUS is much underused as a fluid stop point – most of its use is on the ‘let’s find a cool reason to give.’  I would argue that you should hardly ever give fluid to a full IVC (especially if markers of pathological congestion are present – portal vein pulsatility and all), unless you are dealing with temporarily improving tamponade or tension pneumo, because even if you are volume responsive, you are likely not volume tolerant. This also goes to the point that a single, initial POCUS exam will potentially not have the same impact as a whole POCUS-based management which will use it to reassess congestion status, cardiac function, etc.

Having said all this, the most important part of the SHOC-ED article is, in my mind, their discussion, which is full of all the important reasons why the final conclusion is not `we don’t need to do POCUS in shock,’ which is what I see happening (similarly to the TTM reaction), as they outline the cognitive fallacy of putting on trial a diagnostic tool whilst the therapeutics are not yet clearly established. Those only reading the abstract or conclusion will actually miss the important points of this study which the authors clearly explain.

In particular, the ‘rare’ instances of tamponade or aortic aneurysm or PE in their series would be diluted out by the sepsis, but for those patients, it would matter. As the authors state:

‘one might argue that even a single unanticipated emergency procedure would justify the use of POCUS in critically ill patients.‘

I would have to wholeheartedly agree.

cheers

 

Philippe

November 4, 2018

H&R2019! Final Programme. Register Now! Montreal, May 22-24, 2019! #HR2019

This event is past. It was awesome. If you really wish you’d been there, you can catch most of it here!

And don’t miss H&R2020!

Click here to register!

Registration is open and we have said goodbye to the snail mail process. Fortunately, we are a lot more cutting edge in medicine than in non-medical technology.

We are really excited about this programme, and a lot of it comes from the energy and passion coming from the faculty, who are all really passionate about every topic we have come up with.

The hidden gem in this conference is the 4 x 40 minutes of meet the faculty time that is open to all. Personally I’ve always felt that I learn so much from the 5 minute discussions with these really awesome thinkers and innovators, so wanted to make it a priority that every participant should get to come up to someone and say ‘hey, I had this case, what would you have done?’   Don’t miss it!

CME Accreditation for 14 hours of Category 1.

This programme has benefitted from an unrestricted educational grant from the following sponsors (listed alphabetically):

Cook

Fisher-Paykel Healthcare

GE Healthcare

Maquet-Gettinge

Masimo

Medquest

MD Management

Medtronic

Novartis

Teleflex

 

The Accreditation is as follows:

 

Here is the Final Programme:

Final Programme

Wednesday May 22 – PreCongress course

  1. Full day Resuscitative TEE course

FOR DETAILS SEE HERE

 

    2. Full day Keynotable

    3. Half day Hospitalist POCUS (PM)

    4. Half day Critical Care Procedures (AM)

    5. Half day Brazilian Jiu-Jitsu for MDs (AM)

for more details on these pre-conference courses please see here.

 

Main Conference Programme: H&R2019 Full Pamphlet

Social Events:

Thursday May 23rd Meet the Faculty cocktail! 1900 – Location TBA – BOOKMARK THIS PAGE!

 

Register here!

FOR ANY QUESTIONS CONTACT HOSPRESUSCONFERENCE@GMAIL.COM.

 

September 27, 2018

H&R2019 Pre-Conference Courses. May 22nd. Yup, it’s worth coming early!

So we are very, very excited about our pre-conference course lineup. It is simply awesome:

1. Full day Resuscitative TEE (Limited to 20 participants) 0830-1730

H&R2019 REGISTRANTS SHOULD RECEIVE A CODE ENABLING REGISTRATION. FOR ANY QUESTIONS CONTACT HOSPRESUSCONFERENCE@GMAIL.COM.

2. Full day Keynotable 0830-1730

3. Half day Hospitalist POCUS (Limited to 30 participants) afternoon 1330-1730

4. Half day Critical Care Procedures (Limited to 20 participants) morning 0830-1230

5 .Half day Brazilian Jiu-Jitsu for MDs (Limited to 30 participants) morning 0900-1200.

 

Note that sadly, you have to make some choices. No way to attend it all…

 

So here is some info to help you make your best pick:

 

1. Full day Resuscitative TEE: run by none other than Felipe Teran, and featuring Andre Denault as head instructor, this is a unique opportunity for a deep dive into everything about TEE in shock/arrest as well as extensive hands-on training on shock/arrest TEE using state-of-the-art simulators. Participants will obtain an Optional Competency Assessment,  providing a Workshop Certificate and a Focused TEE Competency Assessment Checklist certifying completion of 10 proctored examinations.

Limited to 20 participants. 795$USD. Note that conference registrants (minimum one day) will be prioritized for registration to this workshop, with proof of H&R2019 registration required. Remaining spots will be released to non-conference attendees on March 1st, 2019.

TEE Day PROGRAM

Flyer

 

Keynotable Montreal Flyer

2. Full day Keynotable: the brainchild of educator extraordinaire Haney Mallemat, this course is intended for those who want to add some serious game to their presentations and didactic teaching. Sharing tips and pearls that have made him unquestionably one of the best docs to man the stage and podium, this is a rare opportunity not only to leave run-of-the-mill powerpoints behind, but also to enhance your future audience’s learning and become a master presenter.

Registration 495$USD physicians, 375$USD trainees and other health care professionals. Register at http://www.keynotable.net or email info@keynotable.net.

More details here.

 

3. Half-Day Hospitalist POCUS: Learn absolutely necessary skills for the day-to-day management of your hospitalized patients. It doesn’t matter how good a clinician you are, with ultrasound you will be a better one. Learn from a world-class clinician faculty how to assess the IVC for a number of clinical scenarios, how to assess lungs, do basic cardiac views, diagnose or rule out hydronephrosis, and safely tap ascites or pleural effusions.

Cutting edge today, standard of care tomorrow…

Faculty: Rola, Ajmo, Haycock, Baker, Olusanya

Practice on state-of-the-art simulators, normal volunteers and volunteer patients with true pathology.

Your patients need you to know this.

Limited to 30 participants so that your hands on and faculty experience is maximized. 300$CAN/250$USD

 

4. Half-Day Critical Care Procedures: If you are not already familiar with these key procedures any resuscitationist should have in their pocket, don’t miss this course. We’ll go over thoracic pigtail insertion, bedside percutaneous tracheostomy and emergency surgical airway, using manikins and natural simulators. Plenty of practice, until you’re comfortable with the techniques. By the end of this activity, participants should be able to independently insert pigtail catheters and perform an emergency surgical airway, and be able to perform a percutaneous tracheostomy with the backup and supervision of an experienced operator.

Faculty:  Ajmo, Farkas, Tremblay

Limited to only 20 participants, so don’t wait too long! 300$CAN / 250$USD

 

 

 

5. Brazilian Jiu-Jitsu for MDs: Nope, you didn’t accidentally click on a link. This is part of the pre-conference day. What does it have to do with medicine? A lot. With life? Everything. If you’re already got mad mat skills, come join us for a couple hours of fun. If not, treat yourself to an introduction into a martial art, a sport and even a lifestyle that cultivates physical and mental health like no others. The rest of the conference will change your practice, but this workshop might change your life.

Faculty: Spiegel, Rola, and some guest stars!

No experience necessary, only interest and enthusiasm.

It’s a bit too early to be sure who, but expect to have some interesting surprises as to who your instructors might be…

…oh, and acute care docs should find something in the words of Rickson Gracie, one of the legends of jiu-jitsu:

Limited to 30 participants, registration fee TBA, and will open on november 1st. You can reserve your spot in the meantime by emailing hospresusconference@gmail.com.

 

So we are really looking forward to these courses. It’s a great opportunity to pick up some important skills and have plenty of time with some awesome instructors, all of whom are hoping to share as much clinical knowledge as possible.

Mark your calendars! Please email hospresusconference@gmail.com with any questions!

Register here!

 

The H&R Scientific Committee – St-Arnaud / Zambrana / Rola

August 28, 2018

The Resus Tracks 04: Shock Circulation & Renal Perfusion with Korbin Haycock. #FOAMed, #FOAMer, #FOAMus

 

So I got to have a chat with ER doc extraordinaire Korbin Haycock today, reasserting my belief that tissue perfusion is not proportional to blood pressure.  I am again including the article discussed, and here is the graph in question:

Here is our talk:

And the paper – which is definitely worth a read, as it clearly supports individualizing therapy!

MAP in sepsis review

 

cheers and please jump into the discussion!

 

Philippe

August 21, 2018

The Resus Tracks 03 – Shock Circulation with @EMnerd! #FOAMed, #FOAMcc, #FOAMer

Here we go!

 

Discussing with Rory is always awesome, because he manages to distill things to the most important stuff. In this one he basically says sure Phil, it’s fun to think up all kinds of semi-theoretico-imaginary hemodynamic stuff, but you gotta make sure you control the source!

Thanks!

 

Love to hear comments and criticisms!

 

Philippe

 

Here is the open access paper I was talking about, graph on page 2.

MAP in sepsis review

 

May 15, 2018

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

 

 

 

February 22, 2018

Kylie & Korbin chime in to the Venous Congestion Issue. #FOAMed, #FOAMcc, #FOAMus

So I think much of the awesomeness of #FOAMed is sparking discussion and exchange, and the many little steps in clinical management besides the initial prescriptions. So I thought I would highlight and exploit a couple of really interesting reader comments:

So first, Kylie (@kyliebaker888):

Great to listen guys, thanks, and very timely. I had just read Tremblay’s paper after coming across a very pulsatile PV in a relatively well elderly patient with bad TR. Two questions – which PV are more likely pulsatile in the first place….Tremblay mentions RVF/TR and very thin folk. What is your experience?
Second Question – what did the GB wall/GB fossa look like after the initial very positive fluid balance? Does everyone blow out their GB wall with fluids, or only some?

It is always important to isolate the patients’ whose physiology may change the clinical signs (in this case PV pulsatility) and make their interpretation different. I agree that massive TR, especially chronic, would likely account for pulsatility. I am not certain about the physiology for the very thin patient, but I have heard the same thing from Andre.  So my personal take on a patient with severe TR and a pulsatile PV would be to look at the IVC variation, TR notwithstanding, if it is fixed and plethoric I would diurese – the organs don’t care what the cause of the congestion is.  

As for the GB, I have also seen edema, and then try to correlate with cholestatic enzyme changes that would be out of proportion to the hepatocellular enzymes if there is a primary GB process. This is certainly an imperfect science. In a critically ill septic patient, I have a low threshold to drain the GB if in doubt.

Then Korbin gives his two cents, and then some! 

Great case, loved it. Thoughtful management, brilliant!

I couldn’t help thinking as I listened, that it is so important to avoid over-resuscitation with fluids in the first place. We all know that the majority of crystalloids given will end up as interstitial edema, so any benefit from the increase in stroke volume is temporary at best (consider carefully what you gain and at what cost). Wet lungs=increased mortality, days on the vent, and ICU stays. Wet kidneys=AKI 2-3 days after initial resuscitation and potential RRT. Congested liver=gut edema and continuation of inflammatory cytokines/sepsis syndrome. Too much fluids–>BNP levels rise, high BNP levels in the presence of LPS=glycocalyx shedding, and more interstitial edema everywhere.

Cannot agree more.

I think there is some decent evidence that an early fluid liberal approach combined with a late fluid restrictive approach can potentially benefit a patient in septic shock, but its clear that an overall positive fluid balance does harm. Perhaps, even the early fluid liberal strategy (in sepsis specifically) should be tempered by a careful consideration of what is really going on.

My take here is that, by using POCUS, there is no need for a “general approach.” POCUS takes essentially no time. In about 5 seconds you can confirm a small IVC that can (initially) take fluid, a medium one (that you need to watch) or a full one (yes, it happens – that gets no fluid). So to me there is no need to have a pre-determined approach…

Sepsis is an entity characterized by venous return being limited by a decrease in mean systemic pressure (MSP) due to an increase in venous capacitance, rather than a decrease in fluids that generates the stressed volume (MSP=fluid filling/venous capacitance). The body compensates with an adrenergic response that maintains (or attempts to maintain) MAP by an increase in a catecholamine driven augmentation in cardiac output/contractility. This adrenergic response likely has more to do with the increase in lactate production observed in sepsis, rather than actual tissue hypo-perfusion and anaerobic metabolism mechanism. Increases in CVP inhibit venous return and congest the kidneys and GI tract (the left atrial pressures are the equivalent problem for the lungs, combined with the fact that pulmonary vascular permeability is increased in sepsis as well). Given this, I think in distributive shock, we should fix the lack of MSP by an earlier vasopressor therapy approach, both to supplement and decrease the crystalloid load to the patient, which is un-natural and contrary to their deranged septic physiology.

Agree.

Also, could the type of crystalloid given be important? NS gives a considerable sodium load compared to LR, and this likely promotes/sustains fluid retention that is difficult to remove during de-resuscitation. The high chloride levels of NS will promote an increase afferent arteriolar vasoconstriction and thus decrease GFR, making it more difficult to diuresis the patient later on, and contribute to AKI beyond the iatrogenic interstitial kidney edema caused by the crystalloids we gave.

Absolutely. NS is given by medical peeps only by cultural habit. Most do not know the pH (zero SID due to chloride) of  a solution they give by the buckets. RL is the best option I have available.

If you are involved in the early phase of resuscitation of a shocked patient, consider the downstream consequences of your fluid strategy that you give your patient that may give you a temporary comfort because they will look better in the short term.

Dr. Maitland and the FEAST study corroborates exactly this.

This is not to say that an aggressive and upfront resuscitation is not critical–it surely is. I’m saying resuscitate smarter, not wetter. Look for stop points for crystalloids–E/e’ ratios, consider PVPI, RV dilation/TAPSE, hepatic vein doppler, IVC dynamics, portal vein pulsatility, intra-renal venous Doppler patterns and renal resistive index. Fix the hemodynamics from an approach of the root of their problem, rather than pushing fluids for every hypotensive patient (whether you are taking care of them early, or late in the time frame of their illness). Fluids do have their place, but be careful and cognizant of their real down side. Look at your patient, think it through, and make the best actions for them.

Ok, now I don’t even get to have a punchline. Thanks Korbin!

So if this interests you, tune in to The Great Fluid Debate at H&R2018, and I look forward to meeting both Kylie and Korbin who will be in attendance and, I’m sure, putting us all on the spot!

And yes, there will be a POCUS workshop on portal and hepatic vein POCUS.

click here if you want to take part: H&R2018

cheers!

Philippe

 

February 18, 2018

POCUS & Venous Congestion – A Clinical Case Discussion with Rory Spiegel (@EMnerd_), #FOAMed, #FOAMus, #FOAMcc

Hi, so as a follow up to our earlier discussion, which can be found here, Rory and I discuss a recent case he had, which I think exemplifies well many of the clinical conundrums that are seen in fluid resuscitation, one being the general resistance of many to diurese patients who are still in shock on vasopressors, instead preferring to (hopefully) wait until shock resolution to de-resuscitate. But sometimes, it is exactly what they need, as some of this congestion may be, in fact, a cause of shock…

Here you go:

Love to hear opinions, so feel free to reach out.

 

For those who may be interested at learning some of these POCUS skills, check out H&R2018 (#Hres2018)!

 

cheers!

 

Philippe

December 14, 2017

The Hospitalist & The Resuscitationist. Montreal, April 18th & 19th, 2018. #Hres2018

NOTE: THIS WAS THE H&R2018 PAGE, SO IF YOU ARE LOOKING FOR H&R2019, CLICK HERE!

So for this winter, we’ve put together a little gem of a conference which will be a mix of hospitalist and critical care medicine, both with a dash of POCUS for good measure. Our focus here will be short, to the point, highly relevant and highly physiological talks on key topics, in short, 15 minute talks.

What are we going to talk about?

Day 1: The Hospitalist

 

Day 2: The Resuscitationist

 

 

You can figure there will also be late-breakers, “ask the crowd” talks and more.

Workshops? Sure:

Yup. You can ask for a workshop. Enough similar requests will probably make it happen. A few have already asked for Neuro-POCUS, so that is a likely addition.

 

So, who will be talking?  The lineup already includes Andre Denault, Josh Farkas (@Pulmcrit), Jon-Emile Kenny (@heart_lung), Rory Spiegel (@EMnerd), Hussein Fadlallah, Peter Barriga, Daniel Kaud, Davide Maggio, Michael Palumbo, William Beaubien-Souligny, and a few more to confirm. And who knows who might do an impromptu drop-in…

 

The short answer is yes. Of course, it does depend on what you do. If you are a hospitalist, involved in critical care or acute care of any kinds, you will find something here for you. Totally awesome for IM residents/FM residents planning on doing some hospital medicine or ICU coverage. Who will get the most bang for his or her buck here? Real docs training or working in the trenches. This isn’t a cutting edge research conference, but a cutting edge clinical application conference.

 

Oh yes, and the CME, of course:

 

This will be a small, fun conference. Space is purposely limited, for an intimate feel and to encourage discussion between peers. No need for these exclusive “meet-the-professor lunch” or anything like that: that’s what the whole event is like!

 

Registration is open! Print, fill, write a cheque and send the form below:

RegistrationV2

If you’re crazy busy, or have any questions, feel free to email hospresusconference@gmail.com or tweet (@ThinkingCC) to reserve a spot! 

Download the brochure here:

H&R2018 Brochure – Participants

 

cheers!

 

The H&R 2018 Scientific & Organizing Committee:

Dr. Philippe St-Arnaud – ER and Critical Care doc, POCUS instructor and constantly pushing the clinical envelope.

Dr. Carola Zambrana – our Hospitalist on the panel, constantly seeking excellence in care and working on bringing POCUS to the wards.

Dr. Mario Rizzi – our friendly neighborhood respirologist and educator.

Dr. Philippe Rola – Critical Care doc, long time POCUS aficionado and instructor, working at bringing POCUS into the everyday physical exam.