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

 

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

 

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

 

 

 

 

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!

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

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

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!