Fluids or vasopressors or inotropes & why?
CO = HR x SV but altering cardiac contractility or HR (by themselves) won't normally change CO🤯
Here's a 20 minute talk using infographics to try and simplify concepts that often seem very complicated.
#FOAMed
Part 2 of my 'rational fluid prescribing' series 💦
'The micro-circulation'
⭐️Why sepsis doesn't cause hypovolaemia
⭐️The
#glycocalyx
⭐️Extended Starling principle
⭐️Albumin
⭐️Capillary leak
⭐️Where IV fluid actually goes
...and more
#FOAMed
👇
#Vimeo
500 of these just arrived from the printers to help my mission of safer fluid prescribing
@sathNHS
£20 well spent when Fife saved 100k/year. Lots more measures to come to improve IV fluid safety.
6 years in the making. Never again but delighted to get it over the line. Well done to chief editor
@AndrewW21023349
and my fellow editors. Thanks to all the authors.
Want to help fluid prescribing in your Trust? Try printing credit card sized guides to tuck behind an ID badge. Example here from
@sathNHS
For more ideas register for this free webinar:
⬇️
When it comes to haemodynamics, ultrasound can answer the critical questions that need answering at the patient’s bedside.
@ICUltrasonica
, the rest of the
#FUSIC
team and I are proud to present FUSIC HD.
We hope it will greatly benefit patient care.
It's impossible to teach everyone
@sathNHS
about IV fluids so going to put it all on youtube. Think a video lecture series will be better than 1 massive lecture. This is going to take a while but will be well worth it in the end.
@SaTHImprovement
@Fluid_Academy
#patientsafety
Can we distinguish between hypovolaemia and vasodilatation with echo? This concept highlighted by
@IM_Crit_
is one that gets repeated in articles and textbooks. But is it true? This is a really interesting question that requires a 🧵
Ok, I just found where I read that the LV end-diastolic dimensions can help diffentiate hypovolemia from vasoplegia. It was in one of the ASE guidelines papers a few years ago. Time flies!
Lung protective ventilation, setting PEEP, driving pressure, ventilator modes, weaning, asthma, obesity....
@Wilkinsonjonny
and I present this quick guide here:
Interested in expert feedback to make it even better too! (Calling
@charlot_summers
)
What hand-held ultrasound device is best? I recently got my hands on the new
@vscan
and
@Wilkinsonjonny
@ICUltrasonica
and I have been putting it through its paces. Our full review will be coming soon but here I'll show you some comparison pics with
@PhilipsLumify
(gold standard)
To know you are looking at the optic nerve and sheath you need to identify:
1. optic disc
2. retinal vessels with colour doppler
3. hypoechoic nerve
4. hyperechoic sheath
5. shadow on either side of the nerve sheath (which should not be included in any measurement)
This is a short version of 1 of a series of talks I'm releasing on rational fluid prescribing. I'm always trying to make the complex physiology simple and useful in terms of informing practice. I'd love to hear your feedback
#turningthetide
@Wilkinsonjonny
@PARADicmSHIFT
Hypernatraemia is an independent predictor of mortality.
It is common, but completely avoidable, in hospital.
See this 1 page guide for diagnosis and management.
#FOAMed
#hypernatraemia
Want to learn TOE but always thought accreditation was out of reach? No longer.
@ICS_updates
and
@Assoc_Anaes
have collaborated to bring focussed TOE within reach of all acute care practitioners.
Start your journey now:
Aortic dissection is easily missed, carries a high mortality and should be on the differential of any patient with shock, abdo pain or chest pain. Contrary to popular belief the entire aorta can be imaged via transthoracic and abdominal ultrasound. Let’s start with some anatomy
From Guyton to the Glycocalyx. How physiology informs fluid prescribing.
Why:
Sepsis does not cause hypovolaemia.
95% of a fluid bolus can stay in the vessels or leave them.
Oedema is not benign.
What is:
Venous congestion?
Capillary leak all about?
#SOA21
is here! While you're waiting for it to start why not check out the soap box on demand? You can see my talk in tomorrows main session or watch it now.
Capillary leak - misunderstood
Glycocalyx - what does it do?
Rational fluids
Albumin - a waste of time
@ICS_updates
If I could only use 1 thing to guide fluid management in ICU it wouldn’t be
#echo
, other ultrasound, any other kind of cardiac output monitor, CVP, urine output, blood tests etc. It would be my index finger poking the patient in the hip (most dependent area) to look for oedema.
Son injured his wrist playing touch rugby yesterday. Just a sprain I say (no bony tenderness). This morning tender distal radius. Get out the
@PhilipsPOCUS
lumify ultrasound and see this. Now awaiting XR 😜
A lot of excellent answers. This was a patient with days of severe vomiting. Metabolic alkalosis from chloride loss. High lactate from hypovolaemic shock (with high Hb). -13 towards an acidosis but +24 towards and alkalosis (135-73-38) so alkalosis wins. (38 is normal NaCl gap).
Patient on noradrenaline (norepineprine) had it reduced. Explain the changes in the observed numbers on the cardiac output monitor:
MAP 70➡️52
SV 84➡️73
SVV (SV variation) 3➡️8
SVRindexed 1190➡️870
#haemodynamics
1. Lichtenstein described a 12 zone protocol for LUS in 2004. By 2008 he had demonstrated with the BLUE protocol that a 6 zone scan was as accurate. A study in 2011
again confirmed 6 zones were as good as 12...
Lung
#ultrasound
in
#COVID19
: less (zones) is more??
➡️12 vs 6-zone protocol
➡️each zone scored 0 (A-pattern) to 3 (consolidation)
➡️LUSI calculated for both
Monitoring > 6 zones does not appear to provide additional information.
#POCUS
#echofirst
#FOAMus
1 in 5 patients come to harm from fluid mismanagement I'm going to be talking about this @
#SOA22
.
@ICUbreeno
&
@MarciaMcDougall
will be telling you how you can fix this in your hospitals. Come join us next Friday in Belfast or online.
I'm looking forward to talking about fluid management and ultrasound next week in Valencia. 🇪🇸♥️
Tengo muchas ganas de hablar sobre gestión de líquidos y ecografía la próxima semana en Valencia.
#44SEMI
Intensive Care ultrasound fellowship
@SaTHjobs
with me. 50% on call. All other time for ultrasound. Starting August. You can be a novice in US or a ninja looking to hone your skills. 6-12 months available.
Online e-learning now available from
@ICS_updates
for
#FUSIC
ultrasound. All the course lectures for heart, lung, abdomen, DVT and vascular access delivered by our dedicated committee members. Register and learn from the comfort of your own home
#echofirst
Join
@Wilkinsonjonny
@PARADicmSHIFT
and I to find out all about IV fluid management.
Part of
@ICS_updates
free webinar series.
Physiology, evidence and practical advice
📅Feb 4th
⏰20:00
Register here
👇👇👇
Organ perfusion is highly dependent on venous pressures. These are easily assessed with ultrasound. Here are some powerful case histories.
#FUSIC
HD
Thanks to the authors
@ThinkingCC
@curromir
@ArgaizR
@khaycock2
et al 👏👏
Brain ultrasound is not just for neuro intensivists. In a DGH you can use it to answer these questions:
Is there evidence of raised ICP?
Is there midline shift?
Is there evidence of vasospasm?
Is there evidence of impending brainstem death?
Expand your🧠
Does the heart🫀pump blood around the whole circulation 🔃 or is VR driven by elastic recoil? Which camp are you in? Why? And does it matter? Does labelling variables as dependent or independent affect how we treat patients?
Polite debate only please 🙏
Heading back from the best conference I’ve been to after the kind invite from
@ThinkingCC
. Met some fantastic people I hope to keep in touch with and see again. What a faculty! Cutting edge physiology, jiu jitsu and poutine 💪🏻
@HandRConference
This is the best review of R heart echo I have yet read. It will be in the essential
#FUSIC
HD reading list. Congratulations to the authors.
@MaxHockstein
@khaycock2
@msiuba
et al
🚨Calling all
#PoCUS
enthusiasts 🚨
Opportunity to present at the UK's largest critical care conference
@ICS_updates
2021
Competition for top 3 prizes 🥇🥈🥉
Expecting some brilliant cases where management changed & lives saved
Any organ system
🧠🫁🫀🤰
Details in thread
Separation between echo and US is historical as they were traditionally done by cardiology and radiology. In ICU we integrate US with our clinical assessment to diagnose and guide treatment. This may involve any organ system and it should be used, taught and understood as such.
I'm going to be exploring how we can rationally resuscitate our patients at
#ACCS2023
. I'll be debunking some myths about things like fluid responsiveness, how the circulation is controlled, whether we should be targeting pressure or flow and much more!
#haemodynamics
case
60s, known cardiomyopathy EF 25%, presented hypotensive in VT overnight
DC cardioverted. Remained hypotensive
Admitted ICU
Dobutamine started & titrated up to moderate/high dose as remained hypotensive (cardiology advice)
Awake/alert but not PU
AKI on biochem
Chance to present your most interesting ultrasound case at the UK's largest critical care conference. Open to anyone on the planet 🌎🌍🌏
#POCUS
#echofirst
#ultrasound
#FUSIC
See link and thread for details
👇
Thanks to the 413 people who voted and even more to those of you who were brave enough to comment. It’s always difficult to suggest managment on Twitter cases with limited info when you don’t have the patient in front of you. Answer as promised:
#haemodynamics
case
60s, known cardiomyopathy EF 25%, presented hypotensive in VT overnight
DC cardioverted. Remained hypotensive
Admitted ICU
Dobutamine started & titrated up to moderate/high dose as remained hypotensive (cardiology advice)
Awake/alert but not PU
AKI on biochem
You want to optimise organ perfusion? Arterioles auto-regulate organ blood flow above a minimum pressure. So blood flow is determined by organ compartment pressure and venous pressures. Both are increased with XS fluid administration. Listen to
@ThinkingCC
at
#IFAD2020
today
Just a few places left on our
#FUSIC
HD course. If you are competent at basic echo go to the next level by learning to assess the whole haemodynamic system.
Great service
@sathNHS
PRH this morning. In and out in an hour and a half to diagnose and cast a #. Kind, efficient, knowledgeable staff throughout the whole process (ED, XR, plaster room). 👏🏻👏🏻👏🏻
Been banging on about this for years now. There’s no physiological rationale for fluid (beyond daily requirements) in pancreatitis and lots of reasons for harm.
#TurningTheTide
Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis | NEJM
Next week at
#ACCS2023
I'm going to be arguing that brain ultrasound for Intensivists is a waste of time....
...against one of the world's foremost experts in brain ultrasound
@aartisarwal
Wish me luck
@veerappan91050
😆
'Sepsis' = venular dilatation =⬇️Pms =⬇️VR =⬇️SV/CO = ⬇️BP. Accompanied by sympathetic activation (in an attempt to⬆️Pms). Fluid (+/- vasopressors) ➡️ high Pms and arterial dilatation/recruitment. Add the sympathetic stimulation on the heart = hyperdynamic state with low SVR
Very easy to have a high ECF volume and be fluid responsive. You have to be MASSIVELY fluid overloaded (in absence of heart failure) to be fluid non-responsive. The safety of fluid removal in such patients can be quite easily demonstrated by filtration while monitoring BP and SV.
Whilst
#ultrasound
is brilliant for patients I've even found it useful for submission grappling
#BJJ
. Knowing the anatomy of the IVC and seeing its collapsibility with probe pressure means I know where to precisely place every 1 of my 75kg to get a tap from side control pressure.