critical care

June 5, 2024

H&R2025 – The Hospitalist & The Resuscitationist, Montreal, Main conference May 22-23, pre-post courses 21 and 24, 2025. #HR25 – REGISTRATION is OPEN !!!

A few words about it…

HR2025 is about putting it all together. We’ve been talking about the venous side for a long time and it has been fantastic seeing how much it has taken off – at least in the #medtwitter #foamed and PubMed community. There’s enough data out there to show a real clinical utility of consciously examining the venous compartment. This applies to any hospitalized patients, whether in the ED, the wards or the ICU, so that’s why this year, the H and the R will spend the first day together doing all things VExUS and venous congestion, along with the corresponding workshops, again so that participants can leave with some actionable knowledge and skills. Whether you’re a beginner at this or a seasoned veteran, there should be something to learn.

On Day 2, we’ll divide into two tracks. The R side will deep-dive bedside hemodynamics and our 4-interface model of shock management. Of course there will also be some pearls and late-breakers as this is still a year away and there will undoubtedly be some really interesting things cooked up by the crew by then! 

Meanwhile on the H side, Katie and Gigi are thrilled to have put together a top-notch lineup of speakers to teach everyone how to become Inpatient Medicine Jedis. We have some big names in attendance this year, including both new and familiar faces – The Clinical Problem Solvers themselves will take us through some challenging cases; Frederik Verbrugge will drop diuretic truth-bombs; the ever-fabulous @NephroPOCUS will discuss a Bedside Approach to AKI; and Allison Bond will share the Top 10 Infectious Disease Mistakes on the ward, among many others! Day 2 Workshops will be focused on high-yield test interpretation: think EKGs, PFTs and sleep studies, urine microscopy, peripheral blood films, and more! 

https://player.vimeo.com/video/1022725950?h=825106f34a&badge=0&autopause=0&player_id=0&app_id=58479


And as always, the ethos of H&R is about putting together physiological clinicians who love to both push the envelope and share their knowledge and experience. The energy that comes out of this is really quite unique, and the sheer number of successful collaborations that have stemmed from it since 2018 is really impressive. The unplanned, unscheduled small group discussions are the true gems of this conference… Many of the usual suspects will be there, and as always some new additions to the H&R family!

Who? I can’t say enough about the H&R crew. Brilliant, open minded, eager to both learn and teach, no large fragile egos here. So expect to learn from and hang with Sara Crager, Korbin Haycock, Rory Spiegel, Matt Siuba, Eduardo Argaiz, Gigi Liu, Ross Prager, Frederic Verbrugge, Vimal Bhardwaj, Glenn Hernandez, Andre Denault, Jon-Emile Kenny, Ashley Miller, Segun Olusanya, Max Hockstein, Ben Daxon, Abhilash Koratala, as well as some new faces to the live event, very much looking forward to meeting Trina Augustin from Mayo as well as another critical care icon, Professor Jan Bakker, and I’m happy to announce the return of the true father of POCUS, Daniel Lichtenstein, and we will even have the amazing opportunity to (virtually) hear from Dr. Geoff Parkin, one of the pillars of hemodynamic physiology! There are a few more to confirm and we promise they will bring the same enthusiasm and unique experience to the event!

So the most important thing for you to do is to mark your calendars and make sure you don’t miss being a part of it! Bookmark this page as the registration link (november 1) will appear as well as developing programme information! Note that registration fees will be in USD given the international nature of the conference.

Montreal, May 21-24. Core conference May 22-23, Pre and Post-courses May 21 and 24.

Pre/Post congress preliminary courses

  1. BJJ or Self-Defense for Humans & Health Care Workers (May 21st pm)
  2. The VExUS Course (May 21st am)
  3. ArrestTEE Sim Cases (May 21st)
  4. The Great Presenter by Marco Garrone (May 21st am)
  5. Sauv Life (eCPR) by Paris’ Lionel Lamhaut! (May 24th)
  6. Bedside EEG for EDCritters? (TBA)
  7. SEVA Ventilator Course by The Cleveland Clinic’s Eduardo Mireles-Cabodevila! (May 24th)
  8. ResuscitativeTEE Workshop by Felipe Teran (May 24)

for more on these see https://thinkingcriticalcare.com/2024/10/26/hr2025-pre-and-post-courses-hr25/

if there’s a course you want, go ahead and get in touch with us! hospresusconference@gmail.com or via twitter with #HR25 tag.

Schedule 

Day 1 – May 22 

Time Talk/Workshops Faculty 
0800-0815The Concept of Fluid ToleranceRory Spiegel 
0815-0845Bedside Cheat Code – Femoral DopplerVimal Bhardwaj and Andre Denault 
0845-0915An update on the Hepatic VeinEduardo Kattan 
0915-0945Understanding Portal Vein Doppler  William Beaubien-Souligny  
0945-1015Coffee Break
1015-1045Renal Venous Doppler – RVSI and VExUS Eduardo Argaiz (virtual) 
1045-1115eCPR and Organ DonationLionel Lamhaut 
1115-1215Workshops:Mastering the IVC assessment


Hepatic and Portal vein assessments 

Intrarenal hemodynamics

Femoral vein

How I assess congestion at the bedside (Virtual workshop) 
Rory Spiegel, Juliana Kan and Audrey Lacasse Eduardo Kattan and William Beaubien-Souligny
Abhilash Koratala and Korbin Haycock 
Vimal Bhardwaj and Andre Denault 
Ross Prager 
1215-1300Lunch 
1300-1330 Keynote Lecture – The Evolution of Venous Congestion AssessmentAndre Denault 
1330-1400Pulmonary congestion: Mastering lung USDaniel Lichtenstein 
1400-1430 Practical Diastology: Will my Pt get Pulmonary Edema?Frederik Verbrugge
1430-1530Workshops:Diastology, E/e’ and LA size


CVP using Jugular POCUS  (Virtual and in person workshop) 

Lung US

RV assessment (TAPSE, S’, RVH, PASP)

Beside Cerebral Oximetry in congestion
Frederik Verbrugge and Max Hockstein

Jon Emilie Kenny and Korbin Haycock

Daniel Lichtenstein and Marco Garrone 
Matt Siuba, Andre Denault, Juliana Kan and Audrey Lacasse
Phil Rola and Masimo 
1530-1545Coffee break 
1545-1615Fluid Tolerance in the ED – Is It Pertinent? Marco Garrone 
1615-1645Minute Ventilation: Physical Exam Hack?Rory Spiegel
1645-1715Clinical Cases: CongestionAbhilash Koratala

Day 2 – May 23

Time H side talks Faculty R side talks Faculty 
0800-0830 Clinical Problem Solvers: Challenging CasesReza Manesh and Rabih Geha Intro to the circuit & interfaces Sara Crager 
0830-0900Clinical Problem Solvers: Challenging CasesReza Manesh and Rabih Geha0830-0850: What is Coupling?Jon Emilie Kenny 
0900-0930Immune Checkpoint Inhibitor Toxicity

0930-0940: Buffer 		Laura Cappelli 0850-0910: Understanding MSFP

0910-0940: Resurrecting Blood Pressure. Curious Cases of B12 for Vasoplegia		Ashley Miller and Korbin Haycock 

Ben Daxon 
0940-1040Workshops:Approach to acid-base problems (Virtual and in person workshop) 

Rory Spiegel 



Workshops:LVOT VTI 



Capillary refill time


POCUS AMA





Hemodynamic Pearls Part 1 
Sara Crager, Trina Augustin and Jeff Scott  
Glenn Hernandez and Eduardo Kattan

Jay Chatterjee, Jon Emilie Kenny and Marco Garrone
Ashley Miller
1040-1110Coffee break 
1110-1140Oncologic EmergenciesAditi Singh Interface 1: LV-VA coupling & How I Measure it Max Hockstein 


1140-1210Bedside Approach to AKIAbhilash KoratalaInterface 2: Macro-Micro Glenn Hernandez  
1210-1300Lunch 
1300-1330Keynote Lecture –  “Fill him up to his eyeballs.” Jan Bakker 
1330-1400Acute decompensated heart failureFrederik VerbruggeInterface 3: Capillary-Venular Eduardo Kattan
 
1400-1430High output heart failureEduardo Argaiz – (virtual)Interface 4: RV to PAMatt Siuba 
1430-1530Workshops: Urine electrolytes and microscopy  
POCUS AMA
Abhilash Koratala 


Daniel Lichtenstein and Sara Crager  		Workshops: POCUS RV-PA coupling
PA catheter (3 simulators)



Hemodynamic Pearls Part 2 (Virtual and in person workshop)
Matt Siuba and Korbin Haycock 
Katrina Augustin, Jeff Scott and Andre Denault
Ashley Miller 
1530-1545Coffee break
1545-1615Management of Non-Insulin medications in the hospitalized patient Elias Spanakis Can Starling and Guyton Collaborate at the Bedside? Geoff Parkin and Segun Olusanya (virtual) 
1615-1645Next level BiPAP and CPAPSegun Olysanya (virtual)Impella in Cardiogenic Shock – What Every ER and ICU Doc oughtta know!Katrina Augustin 
1645-1715Top 10 Infectious Disease Mistakes on the WardsAllison Bond Putting it All Together Rory Spiegel 

Registration – https://ccusinstitute.wixsite.com/ccus/events/hr2025-fluid-tolerance-all-things-vexus-shock-hemodynamics

There will be a number of different registration options so please select carefully. Please note that for online-only registrants, we will follow a fee scale using the World Bank country classification system, so click the link below if you’re not sure what applies to you (this applies to where you live/work, not your country of origin).

https://blogs.worldbank.org/en/opendata/world-bank-country-classifications-by-income-level-for-2024-2025#:~:text=Explore%20the%20updated%20World%20Bank%20country%20income%20classifications%20for%202024-2025,

Scientific Committee – Dr. Philippe St-Arnaud (Santa Cabrini Hospital, Montreal), Dr. Benjamin Daxon (Mayo Clinic, Minnesota), Dr. Rory Spiegel (Medstar Health, Washington, DC), Dr. Katie Wiskar, (University of British Columbia).

Cancellation policy: Cancellations until April 15th will be accepted and refunded minus a 5% administrative fee. Cancellations until May 1st st will receive 50% refund, and after that date no cancellations will be possible.

Hotel Information: as the hospital is in a residential area there really isn’t very much around. We suggest finding a hotel on the east side of downtown Montreal (east of University ave) or in Old Montreal, for the enjoyment of the city after the conference, especially if travelling with companions. We have found that better deals can be had using websites rather than for us to secure a conference rate (usually +30%). Priceline/expedia/booking.com are fairly reasonable. The hospital is about 20 minutes by uber/cab from these areas.

Thanks to our Sponsors!!!!!

December 7, 2023

H&R’s Advanced Airway & Basic Airway Endoscopy Workshop 2024

The H&R Advanced Airway Workshop 

Santa Cabrini Hospital, Feb 9th, 2024, 1200pm-4pm

Airway/Intubation

Advanced airway skills are a key element of the resuscitationist’s arsenal. In this workshop, participants will be able to tailor their experience and spend as much or as little time as they want in each station to maximize their learning. We will cover basic direct and video laryngoscopy and intubation with and without the use of the bougie as well as bronchoscopic assistance. Emergency surgical airways – both percutaneous and scalper-finger-bougie techniques – will be reviewed and practiced until participants can perform both rapidly and adequately. 

Basic Upper Airway Endoscopy

Endoscopy for basic diagnostic and procedural purposes will be reviewed for obstructive and airway toilet. This will include rhino-pharyngo-laryngoscopy for foreign body/lesion assessment and stridor management in the ER.

Critical Care Endoscopy

Basic bronchoscopy for rapid diagnosis and airway toilet will be covered. This will pertain to most critical care cases where removal of mucus plugs and broncho-alveolar lavage is the bread and butter. Following instruction, each participant will be asked to demonstrate the ability to identify basic anatomy and be able to orient themselves successfully.

Bedside Percutaneous Tracheostomy Course

Participants will spend the last 90 minutes in a separate track focused on the technique and will be asked to perform 5 unassisted techniques to obtain a certificate of adequate completion. {Note that, since this is not an emergency life-saving procedure, this does not qualify the participant to perform the technique independently in clinical practice and will require supervision by an experienced colleague until sufficient experience is attained.}

Participants & Registration

There will be 15 complimentary trainee registration slots and 20 spots for practicing physicians (249$/199$ for CEMTL MDs) and 5 spots including the percutaneous tracheostomy course (349$). Participants will receive a link to pre-course material to watch prior to the workshops. Lunch will be included. There is no formal CME accreditation for this event.

Registration link: https://ccusinstitute.wixsite.com/ccus/events/hsco-hr-airway-course-2024

The Faculty: Dr. Joe Nemeth (ER), Dr. Philippe St-Arnaud – (ER/Critical Care) Dr. Lawrence Leroux (ER/Anaesthesia), Dr. Andy Nguyen (Respirology), Dr. Olivier Abboud (Otolaryngology), Dr. Ian Ajmo (Critical Care), Dr. Philippe Rola (Critical Care).

Programme

Welcome and Lunch – 1230-1300

Stations A: 1300-1400

– Basic DL/VL station (St-Arnaud, Ajmo)

– The Art of the Bougie (Rola)

– Bronchoscopy-guided intubation (Leroux, Nemeth)

– Rhino/pharyngo/laryngoscopy – (Abboud)

Stations B: 1400-1500

– Emergency percutaneous cricothyrotomy (St-Arnaud/Rola)

– Emergency Surgical Airway (Scalpel-Finger-Bougie) (St-Arnaud/Rola)

– Emergency Tracheostomy (Nemeth)

– Bronchoscopy for toilet/foreign body extraction (Nguyen)

Percutaneous Tracheostomy w/ Bronchoscopy Assistance (Ajmo/Rola) 1430-1600

Open Practice and Q&A: 1500-1600

February 7, 2020

Fluid Philosophy & Physiology. #STOWEEM20 Lecture! #foamed #foamcc

 

So I love the UVM EM Update at Stowe. It’s a great little conference, run by my good friend and all around awesome guy Peter Weimersheimer (VTEMsono) ED Pocusologist, and his super team including Kyle DeWitt (@emergpharm), Meghan Groth (ENpharmgirl) and Mark Bisanzo (@mbisanzo). It’s a smooth running show with some really amazing speakers where I always learn a bunch. Had the chance to finally meet Sergey Motov (@painfreeED) and learn from an awesome opioid lecture. And it’s always great to hang with Josh (@PulmCrit) and listen to the pearls!

So here is my fluid talk. The Keynote pdf is just below. Hope there’s a useful tidbit or two in there!

 

PDF: STOWE20 Fluids

So thanks again to Peter and his crew! And the Stowe attendees, as we had mentioned, get to attend H&R2020 at the in-house rate! (Please choose the Special Members rate)

 

Cheers!

Philippe

 

January 29, 2020

VEXUS Lite: Screening for Venous Congestion with Handheld POCUS. #FOAMed, #FOAMus

So recently a colleague asked me about one of my twitter posts where I had put a clip of doing venous congestion assessment using a handheld – which is without pulsed Doppler (PW).  Since VEXUS is predominantly based on Doppler findings, seems like 2D and colour might not cut it, but can it be done in a screening or “lite” fashion?

Definitely. Here is a mini-discussion about it, and some clips below to illustrate.

 

Pulsatile PV

Clearly Pulsatile PV likely near 100%

Ascites, plethoric IVC, pulsatile PV, markedly abnormal HV with “police siren” appearance due to substantial retrograde flow – likely VExUS 3 or C.

Normal looking HV

Markedly abnormal HV

 

Love to hear some questions or comments!

 

of course, lots of VExUS discussions with William Beaubien Souligny, Andre Denault, Rory Spiegel, Korbin Haycock and myself at H&R2020!

cheers

 

Philippe

 

December 30, 2019

The Resus Tracks: Trans-Pulmonary Dilution Catheters in the ED…myth or reality? #FOAMed, #FOAMer

So anyone who knows Korbin (@khaycock2) realizes he is a true trailblazer in the ED, essentially doing cutting edge critical care from the get go in his shock patients. In my mind this should be the goal for any critically ill patients, that they get the highest level care right at entry and for however long they may be staying in the ED until they get to the ICU.

So today, I was really happy to corner Korbin lounging somewhere in sunny California (as 6 inches of snow come down hard in Montreal) to tell me how he is using this technology in his resus patients.

 

 

So this has got me interested in using this technology. I see it as an early warning signal that your patient may be less fluid tolerant than you may think, and that the signs of pulmonary fluid intolerance I use (oxygen requirement, appearance of B lines (FALLS Protocol-style), etc…) have yet to manifest.

So I’m looking forward to hearing Korbin explain this further (during H&R2020!) and in actual cases where the change in management is clear.

 

cheers

 

Philippe

 

 

 

 

December 25, 2019

H&R2019 Lecture Series: A Christmas Special TripleHeader! #FOAMed, #FOAMer

Happy holidays to all, here is a little gift from H&R2019!

So here’s a gem from Kylie, who is my reference point for GI POCUS. Ever since this lecture I’ve been working on upping my abdominal scanning capabilities!

GI POCUS with Kylie Baker

 

Also, if you’ve been working on your Doppler applications, best do so while truly understanding it, both strengths and pitfalls. Here’s the physiology master shedding some light and some insights.

Advanced Doppler with Jon-Emile Kenny

 

And finally, for the airway fans, here’s Rory Spiegel (@EMNerd) sharing his skills with the bougie.

The Art of the Bougie with Rory Spiegel

 

cheers

Philippe

 

For more lectures that will change the way you practice medicine, do try to make it to H&R2020! It is the very ethos of this small conference, to exchange with docs pushing the envelope of acute care as well as like-minded peers. This isn’t the conference to go to if you want to see what most people do and review guidelines. This is the one to go to if you want to be on the cutting edge. Only 100 spots, has sold out every year.  For more info and registration click here!

November 29, 2019

H&R2019 Lecture Series: Denault on POCUS and Delirium! #FOAMed, #FOAMcc

So the pundits still try to claim the lack of evidence for the use of POCUS, bla, bla bla. Just wait till they get a load of this: POCUS in delirium? Master Andre Denault introduces us here to a completely new way of assessing a little known potential aetiology of acute delirium.

 

Here it is, certainly one of the most interesting and forward-thinking lectures of H&R2019:

Denault on POCUS and Delirium.

 

 

 

Don’t forget The Hospitalist & The Resuscitationist H&R2020 is happening May 20-22 and registration is open! Seating is limited…

cheers!

Philippe

October 7, 2019

POCUS Skill: Bedside Percutaneous Cholecystostomy. #FOAMed, #FOAMcc

So one thing we all pretty much agree on is the importance of source control. Biliary sepsis is one of the more common causes of intra-abdominal sepsis, and among those, there is a not insignificant proportion of cases where a percutaneous drainage procedure is indicated, often related to an elevated surgical risk.

This is the case of a 90 year old man with severe aortic stenosis and a perforated cholecystitis with sepsis (AKI, delirium, coagulopathy) admitted to our ICU. Due to the aortic stenosis, surgical mortality was felt to be quite elevated, hence a percutaneous procedure was done.

I am sharing this to make the case that a percutaneous cholecystostomy is not outside the reasonable skill set of a clinician who is both POCUS competent and has solid guided procedural experience (central lines, thoracic or abdominal pigtails, etc) and in my opinion falls into that same category as pericardiocentesis. All the more so for clinicians working in community hospitals without the luxury of a 24/7 IR team, because in many cases, it is simply not reasonable to wait many hours for source control – the fact that the patient may make it alive to the next morning to have a drainage procedure is not relevant, as the ongoing sepsis over several hours may be something he or she does not always recover from in the ensuing days and is not a risk worth taking unless there is no other viable option. In our center the critical care physicians perform this intervention when IR is not available.

Here, an in-plane approach was chosen with a trans-hepatic route in order to avoid potential peritoneal spillage.

POCUS Pearls: 

(1) Always visualize the guidewire inside the intended space.

(2)When dilating, make sure the proximal part of the guidewire within the target area “disappears” ultrasonographically, confirming entry of the dilator. Why? In some cases the wall may give more resistance (particularly an inflammed pericardium) and the dilator may remain outside – cannulation with the catheter will be impossible.

Procedure:

 

POCUS Clips

 

 

 

 

And the nasty stuff:

 

 

 

Some relevant articles:

https://www.ncbi.nlm.nih.gov/pubmed/12040818

https://www.ncbi.nlm.nih.gov/pubmed/29519331

 

Love to hear of others’ experience,

 

cheers

PS if anyone wants a perc chole workshop at H&R2020 , let me know!

 

Philippe

August 22, 2019

H&R2019 Lecture Series: Sharad Patel on Portal Vein Pulsatility and Hyponatremia!

 

 

So here was a late-breaker talk at H&R2019. Portal vein pulsatility and hyponatremia by a nephrologist – intensivist. Love it. Sharad, a really great guy, also recently published a case report on this topic.

There is a lot of stuff on venous congestion in the woodwork, some of which we are involved in, but also some springing up from different places, and this is really exciting, because POCUS gives you a non-invasive tool to assess and differentiate pathological degrees of congestion that really nothing else can with as much breadth, and as part of a comprehensive exam.

Venous POCUS is worth learning, and keep your eye on this space for how it evolves as a clinical tool. Our VEXUS classification will soon have some real substance behind it.

For those who want more H&R2019, the Essentials can be found here!

And here’s Sharad!

August 7, 2019

H&R2019 Lecture Series: Rory Spiegel on Acid Base! #FOAMed, #FOAMer

So here is a really solid lecture by Rory (@EMnerd) on his approach to acid base disorders. Definitely worth a listen, and probably the way I will go about teaching it from now on!

 

His slides can be found here.

For those who want more H&R2019, click here. Category 1 CME likely to come in the next weeks!