venous congestion

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!!!!!

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

 

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!

May 13, 2019

Venous Congestion from different Clinical Standpoints. #FOAMed, #FOAMcc, #FOAMus

 

So last week sometime we had an interesting twitter exchange which made me realize it is important to explain how some of us are using venous POCUS in different clinical scenarios, which is key, because the development of monosynaptic clinical reflexes with POCUS findings is a rabbit hole we should try not to go down. Instead, POCUS should be about asking the right question and taking that answer as a piece of the pathophysiologic puzzle facing us, which may mean intervening sometimes, and sometimes not, for the same given finding, but with different surroundings.

Here is the twitter exchange.

Thanks to those involved in that discussion – it is how we grow!

And here are some thoughts:

For those not up to speed on venous congestion POCUS I put up the chapter that Korbin Haycock, Rory Spiegel and I worked on in this earlier post.

Here are Korbin’s thoughts on this:

I’m very glad Dr. Eduardo Argaiz pointed this case out, as it brings up considerations apropos both chronic venous congestive cases as well as management of acute illness, particularly in sepsis, where we would expect patients to most likely be fluid responsive, but fluid tolerance is largely overlooked with current management strategies by the majority of clinicians.

Phil’s above audio commentary points out the difference is these two broad categories very nicely. If you didn’t listen to it–you should.

With respect to chronic venous congestive conditions, the knowledge and application of Doppler assessment to therapy will hopefully be the next advance in management at large. Already, I think there is more than adequate research available to show the value of Doppler POCUS (D’POCUS, D/POCUS, or DPOCUS?) in managing these patients. It’s only a matter of clinicians willing to commit to learning and integrate this technology into their skill set.

With respect to resuscitation of the acutely ill patient, there is by far less data, and we are probably into the realm of N=1 here, in terms of how to manage these patients. But, I personally believe–and I understand this is my opinion–that current trends in resuscitation (especially sepsis resuscitation), largely ignores the effect of over volume resuscitation and the potential downstream damage inflicted on our patients.

This theoretical damage of over aggressive fluid resuscitation is multifactorial, including glycocalyx shedding issues/endothelial dysfunction, positive fluid balance and EVLW causing increased mortality (which there is ample evidence for, I think), venous congestion leading to perfusion injuries to encapsulated organs, such as the kidney (AKI) and brain (congestive encephalopathy), and end organ edema leading to the perpetuation of a malignant inflammatory syndrome (portal HTN and gut edema).

In the case called out by Dr. Argaiz, (which can be reviewed by the previous post on this website) my patient had an IVC that whilst not plethoric, was not an IVC that one would expect to find in a patient with a typical distributive shock pattern (i.e. increased cardiac output, decreased SVR, and decreased RAP). Firstly, the complicating factor of atrial fibrillation with RVR was central to the patient’s shock state, however this was quickly addressed with rate control. However, in addition, this particular patient did exhibit additional signs of venous congestion. The portal vein was pulsatile and the intrarenal Doppler pattern was interrupted/bi-phasic in nature. Granted, a pulsatile PV Doppler could be interpreted as related to the hyper dynamic nature of septic shock (as the esteemed Dr. Denault correctly cautioned in his comments on the original post), however a less than flat IVC and the intrarenal findings gave weight to a venous congestive hypothesis as a cause the PV findings as well as a possible cause for his AKI evident on his initial labs.

With this particular case, given my personal global POCUS/FOCUS assessment of his increased LAP (high E/e’), RV dysfunction, RAP, PV, and intrarenal Doppler venous pattern, AND that fact that the RRI was insanely high with an AKI, I elected to treat my hypothetical construct of his renosarca with furosamide and his RRI with vasopressin (as the NE infusion did increase his MAP, BUT NOT decrease his RRI–which the vasopressin infusion did decrease, or so I presume as no other therapeutic interventions were given with respect to the time frame the RRI decreased).

In the end his kidneys had recovered by the next morning, which I’m sure that any intensivist will admit is the opposite of the norm, as the kidneys usually get, at least transiently worse initially-being the delicate sissies/whimps that they are. Whether this was because of the diuretic or the vasopressin, or something else, is debatable for sure, but it sure didn’t get better by 30 cc/kg of crystalloid mandated by CMS, because he got not a drop more than what was needed to push the diltiazem, the lasix, the antibiotics, and the vasopressors.

So to summarize, in the case of chronic cardiogenic venous congestion, clinician realization and adoption of Doppler assessment of this entity will likely be the next leap in improvement in the management of these patients. In the case of acute resuscitation, venous congestion may be a bit more nuanced, and a more comprehensive evaluation is in order in a case by case fashion. However, I think recognition of the issues of over aggressive volume administration will probably be the next frontier in sepsis resuscitation.

 

Love to hear your thoughts!

Cheers

 

Philippe

April 18, 2019

POCUS & Venous Congestion: a #FOAMed Collaborative Chapter.

 

So given the importance of these topics, the number of questions and discussions we’ve had on the twitterverse, and most importantly in the spirit of #FOAMed, here is the chapter from the POCUS book which was co-authored by Rory Spiegel (@EMnerd), Korbin Haycock (@korbinhaycockmd) and myself.

Venous Congestion Chapter

We’re also in there introducing our VEXUS score, and if anyone wants to use/validate it clinically, please do!

Love to hear anyone’s thoughts!

 

PS we’ll all be at H&R2019 and running workshops on venous congestion:

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

The rest of the chapters are here on Amazon and the e-version here on iTunes!

 

cheers

 

Philippe