H&R2019 Preliminary Programme!

 

So things are coming together really nicely. With a couple of attendees from last year becoming speakers, and the addition of some local talent, we’re back for another run. A bit bigger, yes, but not so big that the informal and inclusive atmosphere is lost. In order to really add some more in-depth, take-home skills, we have added the pre-congress courses (see here for more detail) which are truly awesome and will have participants leave with some very concrete and usable clinical skills.

Now there will be a few more additions to the programme, but this should give everyone a pretty good idea of what they are signing up for:

H&R2019 Preliminary Program

One of the things we are really striving to do is to tie things in together. For those of you who followed the posts on venous congestion, or on MAP and perfusion, everyone involved, Rory (@EMnerd), Josh (@Pulmcrit), Jon (@heart_lung), Segun (@iceman_ex), Korbin and the rest of us will be working to crystallize concepts and clinical applications in the huge grey zone that is acute resuscitation.  I am particularly interested in Felipe Teran’s (@FTeranMD) discussions on arrest physiology, because, as opposed to theory-based protocols and guidelines, guys like Felipe are using real-time physiology to guide resuscitation. As far as I’m concerned we all need to move towards this type of resuscitology as opposed to the blind recipe approach.

The workshops will be really cool. In the Castlefest-style, participants will be able to focus on the ones they really want to work on, or else give all of them a try. And there should be some pretty unique ones, such as portal and hepatic doppler, renovascular POCUS as well as a REBOA and ECMO workshops.

We should have registration up and running by november first. There is a 100 participant limit, so don’t wait too long, as we sold out last year!

Montrreal, May 22nd to 24th!

If you’ve got questions, please email hospresusconference@gmail.com or leave a comment!

cheers!

 

Philippe

Shock Macro and Micro-circulation: Piecing things together. (Part 1) #FOAMed, #FOAMcc

 

So I have really, really enjoyed the discussions I had with these bright people on shock circulation:

Segun Olusanya (@iceman_ex) Resus Track 2

Rory Spiegel (@EMnerd) Resus Track 3

Korbin Haycock (tell him to get on twitter) Resus Track 4

Jon Emile (@heart-lung)  Resus Track 5

 

Some take home points so far:

I think that more questions than answers truthfully came out of this, and that is really the best part. But lets see what the common agreed upon thoughts were:

a. the relationship between the MAP and tissue perfusion it quite complex, and definitely not linear. So scrap that idea that more MAP is more perfusion. Could be more, same, or less…

b. you can definitely over-vasoconstrict with vasopressors such that a increasing MAP, at some point, can decrease tissue perfusion. Clinically, we have all seen this.

c. no matter what you are doing theorizing about physiology and resuscitation, THE MOST IMPORTANT IS TO CONTROL THE SOURCE!

 

Some of the interesting possibilities:

a. Korbin sometimes sees decreasing renal resistive indices with resuscitation, particularly with the addition of vasopressin.

b. the Pmsa – can this be used to assess our stressed volume and affect our fluid/vasopressor balance?

c. trending the end-diastolic velocity as a surrogate for the Pcc and trending the effect of hemodynamic interventions on tissue perfusion.

This stuff is fascinating, as we have essentially no bedside ability to track and measure perfusion at the tissue level. This is definitely a space to watch, and we’ll be digging further into this topic.

 

Jon-Emile added a really good clinical breakdown:

I think one way to think of it is by an example. Imagine 3 patient’s MAPs are 55 mmHg. You start or increase the norepi dose. You could have three different responses as you interrogate the renal artery with quantitative Doppler:

patient 1: MAP increases to 65 mmHg, and renal artery end-diastolic velocity drops from 30 cm/s to 15 cm/s
patient 2: MAP increases to 65 mmHg and renal artery end-diastolic velocity remains unchanged.
patient 3: MAP increases to 65 mmHg and renal artery EDV rises from 10 cm/s to 25 cm/s

in the first situation, you are probably raising the critical closing pressure [i know i kept saying collapse in the recording] relative to the MAP. the pressure gradient falls and therefore velocity falls at end diastole. one would also expect flow to fall in this case, if you did VTI and calculated area of renal artery. in this situation you are raising arteriolar pressure, but primarily by constriction of downstream vessels and perfusion may be impaired. ***the effects on GFR are complicated and would depend on relative afferent versus efferent constriction***

in the second situation, you have raised MAP, and probably not changed the closing pressure because the velocity at the end of diastole is the same. if you look at figure 2 in the paper linked to above, you can see that increasing *flow* to the arterioles will increase MAP relative to the Pcc [closing pressure]. the increase in flow raises the volume of the arteriole which [as a function of arteriolar compliance] increases the pressure without changing the downstream resistance. increasing flow could be from beta-effects on the heart, or increased venous return from NE effects on the venous side activating the starling mechanism. another mechanism to increase flow and therefore arteriolar pressure relative to the closing pressure is the provision of IV fluids.

in the third situation, MAP rises, and EDV rises which suggests that the closing pressure has also fallen – thus the gradient from MAP to closing pressure rises throughout the cycle. how might this happen? its possible that raising the MAP decreases stimulus for renin release in afferent arteriole, less renin leads to less angiotensin and less efferent constriction. thus, paradoxically, the closing pressure falls with NE! another possibility is opening shunts between afferent and efferent arterioles [per Bellomo]. as above ***the effects on GFR are complicated and would depend on relative afferent versus efferent resistance changes***

 

This is really, really interesting stuff. So in theory, the MAP-Pcc gradient would be proportional to flow, so if we can estimate the direction of this gradient in response to our interventions, we may be able to decrease iatrogenism. I’ll have to discuss with Jon and Korbin which arterial level we should be ideally interrogating…

More to come, and next up will be Josh Farkas (@Pulmcrit), and I’m sure anyone following this discussion is looking forward to what he has to say. I know I am.

cheers!

 

Philippe

The Resus Tracks 05: Kenny (@heart_lung) Tackles Shock Perfusion! #FOAMed, #FOAMcc, #FOAMus

So finally got around to corralling Physiology Jedi Master Jon-Emile Kenny for a chat, which is always a tremendous learning opportunity. And this time was no different. Jon breaks down some of the mysteries around arteriolo-capillary coupling and shock flow, and brings up some really interesting potential uses of the critical collapse pressure of small arterioles, and hints at how we may be able to use some POCUS techniques to clinically assess tissue perfusion.

Here you go:

Please leave comments and questions!

The article we refer in the beginning to is here:

MAP in sepsis review

And the article on critical closing pressure in the neurocirculation that Jon refers to is here:

CrCP Brain

cheers!

 

Philippe

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

Working out the Clinical Kinks in Venous Congestion: A Discussion w/Rory & Korbin. #FOAMed, #FOAMcc, #FOAMus

It’s really exciting to be at the outer frontier, trying to figure out some new clinical areas. Now these have all been described, however the ability of clinicians to properly identify certain pathophysiological findings has been limited prior to POCUS. Following the trail being blazed by Dr. Andre Denault, we are also working on expanding the applications, particularly in resuscitation/deresuscitation and CHF/AKI. There are more questions than answers, but that’s exactly why it’s interesting.

So for those unfamiliar with the topic here is a small intro:

And for those following, here is the discussion:

 

Do expect more from us about this. Watch this space. It is practice changing.

 

Additional resources:

Here’s a link to the article referenced during the recording: https://www.ncbi.nlm.nih.gov/pubmed/29573604

Andre and I discussing venous congestion

…if you dig around the blog in the past year there are a bunch more!

 

do share your thoughts!

cheers

 

Philippe

 

CCUS Institute POCUS & Resuscitationist Mini-Fellowship: Evolution.

 

So over the last couple of years, the POCUS Mini-Fellowships have been slowly but steadily morphing into POCUS-Resus training.  With POCUS essentially critical in all aspects in resus, including venous congestion assessment, ventilation, diagnostics, it is a natural extension to blend the exchange into many of the other tools that we use, including discussions around fluids choices, pressor choices, monitoring using NIRS tissue oximetry, ETCO2, and overall resuscitation strategies.

Some structured workshops will include percutaneous pigtail insertion, vascular access phantom practice and both surgical and percutaneous surgical airway manikin practice, depending on participants’ choice.

We have recently expanded with the addition of Dr. Philippe St-Arnaud, ER and CC doc and EDE (Emergency Department Echography) Instructor extraordinaire, who will increase our availability – which had been fairly limited – apologies to those whom we could not accommodate due to scheduling reasons.

This is an excellent complement to an RLA (I’m part of that faculty) or ULA fellowship, to bring a real clinical experience into the mix.

Of course, if you are a canadian resident you can get a whole month of this for free by doing an ICU elective at Santa Cabrini Hospital (well, americans are also welcome but more hoops to jump thru!).

For more details and registration information see here.

And here is some of the most recent feedback from the fellows:

Anyway, I wanted to say thank you again. You have inspired our group to continue to move POCUS into our clinical practice; we have started a fluid management algorithm in our observation unit, and hoping that the soon-to-be-added ButterflyIQ to the unit will improve its utilization. Over the last few years, we have caught a few myocarditis cases and new CHF cases initially placed in observation as “influenza,” managed hundreds of CHF cases, and had a handful of +FAST exams in our ED that we were not quite expecting (in fact, having one that was just texted to me from a co-worker is what prompted this email!).   Our POCUS program is still in its infancy, but I think the horse is out of the barn at this point. On behalf of all of our patients that we will see, thank you.

Additionally, I have gone on to co-direct a sono-wars type event at our national physician assistant conference (AAPA), for PA students. At the inaugural event, we had free workshops and a competition that included 200 student learners, representing about 30% of PA programs from all over the country. We opened a huge door for PA programs to start implementing POCUS longitudinally within their curriculum. We received amazing feedback on the program, and are hoping to publish results soon (currently with journal editors)… 

I am excited to pay forward my debts to those that have helped me.  You not only helped me, but generations of PA’s for years to come. Thank you so much for your time and commitment to excellence. What you do matters; please keep running the mini-fellowship! Patrick Bafuma EM PA @EMinFocus, Hudson Valley, NY, USA.

 

        This review is for the CCUS Institute Bedside Ultrasound (US) Mini-Fellowship. I was fortunate to do the mini-fellowship after the Hospitalist & Resuscitationist conference, and I was able to put into practice various techniques that we learned. Dr. Rola was a pleasure to work with and was well-versed with the latest US and free online access meducation (FOAM). The atmosphere was conducive to learning, and we picked up an ultrasound almost immediately and used it extensively through each day. We used various US machines and were able to get a good feel for all of them. My US experience before the mini-fellowship had been a two-day introductory course with healthy medical students as volunteers. At the mini-fellowship, being able to learn on actual critically ill patients was illuminating and helped cement what I had learned. We also went over relatively new bedside techniques such as point-of-care trans-cranial doppler (TCD) and optic nerve US (ONSD). Overall, the experience was well worth the 2800 mile trip, and I would enthusiastically recommend it to anyone that is interested in learning practical applications of US. – Dr. Pranay Parikh, Los Angeles, USA.

 

So join us for a few days of intense, real clinical learning.

cheers,

 

Philippe

Renovascular #POCUS: Technique with Korbin Haycock. #FOAMed, #FOAMcc, #FOAMus

Korbin Haycock, ER doc extraordinaire.

 

So a few months ago I got to talking with Korbin about POCUS, fluids and resuscitation, only to find out this guy is doing all sorts of awesome stuff in his ED in sunny California.  Got to meet him at H&R2018 and he had even more tricks up his sleeve he was telling me about. He will definitely be back for H&R2019 on the faculty side of things.

In the meantime, let’s review renovascular ultrasound with him:

And here is our discussion that took place at TheRounds Backstage during #HR2018.

Interesting stuff. It isn’t always so easy to get a nice renal view in ICU patients, but with some perseverance you often can. I’ve been toying with it and tying it in with the hepatic and portal flow patterns, but I have to admit I had sort of dismissed renal resistive index based on what I could find in the literature, that is until I got to chat with Korbin, who made me see there are some interesting avenues, especially the example he states on seeing it improve with vasopressin use in shock patients, which correlates with some of the data out there suggesting decreased need for RRT and better outputs with vasopressin on board.

I have a feeling there is relevance to this in acute care, and that the next couple of years will reveal some usefulness. The glitch had always been in not knowing what the baseline RRI is, and that it can be abnormal in chronic RF. There are, however, many patients who were perfectly well previously and where the assumption that their baseline is normal is probably safe.

Love to hear comments from anyone using this!

 

cheers

 

Philippe