J. Roberto Mancilla 🧢

MD Urgencias

[El Estoico | Filosofía @ElArteDeVivir__]

La disciplina es elegir lo que quieres a largo plazo sobre lo que deseas en este momento.

[Alexander Fajardo 🇨🇴 @AlexLP_13]

-¿Es que nadie piensa decirle algo a este gobierno fascista? ¡Mataron a un menor!

-Señora Carrascal, ese era el alias.

-¡Pero también mataron a una bebecita! Nos estamos demorando en salir a las calles.

-Señora Carrascal... Ese era el alias de la novia.

[J. Roberto Mancilla 🧢 @JMancillaleon]

@anthrexmde @puentesfabi ☠️☠️☠️☠️

[Diana Coronado @lacoronadation]

Llegó una tutela que busca frenar los bombardeos. ¿Por qué no llegan tutelas que busquen frenar el reclutamiento de menores de edad? La coherencia.

[Dr. Chacón-Lozsán F .'. @franciscojlk]

Critical Physiology Series #56

Lactate Clearance in Shock: What Does a Falling Lactate Really Mean?

Lactate is one of the most useful dynamic markers in shock.

But “lactate clearance” is often misunderstood.

The usual bedside calculation is:
Lactate clearance (%) =
[(initial lactate - later lactate) / initial lactate] × 100

It measures the change in circulating lactate concentration over time.

Blood lactate depends on two processes:

Production and removal.

Lactate production may increase because of tissue hypoperfusion and anaerobic glycolysis, but also because of accelerated aerobic glycolysis, adrenergic stimulation, inflammation and increased metabolic activity.

Removal occurs predominantly through the liver, with an important contribution from the kidneys and oxidation by other tissues.

Therefore:

Lactate concentration = production versus disposal.

A falling lactate can mean improved tissue perfusion and reduced production.

But it can also reflect improved hepatic clearance.

And persistent hyperlactatemia does not automatically mean persistent tissue hypoxia.

This distinction becomes particularly important in septic shock.

Early hyperlactatemia may be strongly influenced by inadequate blood flow and oxygen delivery.

During the first hours of resuscitation, a rapid decrease in lactate is therefore generally reassuring.

Later, however, persistent lactate elevation may increasingly reflect adrenergic driven glycolysis, metabolic reprogramming, mitochondrial dysfunction or reduced hepatic clearance rather than ongoing global hypoperfusion.

This creates an important bedside limitation.

A patient with lactate 5 mmol/L does not necessarily need more fluid.

If MAP, cardiac output, capillary refill, urine output, ScvO₂ or SvO₂ and peripheral perfusion have normalized, giving additional fluid simply to normalize lactate may cause harm.

The opposite is also true.

A lactate that falls does not prove that every vascular territory is adequately perfused.

Regional or microcirculatory hypoperfusion may persist despite improving systemic lactate.

How should lactate kinetics be measured?

Serial measurements are more informative than an isolated value.

Longer trajectories at 6, 12 and 24 hours provide additional prognostic information.

But lactate kinetics must always be interpreted within the shock phenotype.

Epinephrine can raise lactate through β₂ adrenergic stimulation despite improved hemodynamics.

Severe liver or renal dysfunction can slow lactate disappearance.

Seizures, intense muscle activity, ischemic limbs, mesenteric ischemia and some drugs can also increase lactate independent of global circulatory failure.

The bedside message is simple...
Do not resuscitate the lactate!!!
Resuscitate the physiology producing it.

Recommended lectures 📚

Lakbar, 2026, https://t.co/AyC30XTDPC

Levy, 2026, https://t.co/vS3qdEi1Vy

Marbach, 2021, https://t.co/YW8NUM21PV

[Leonardo Santos @Leo_Santo5]

🧠📚Nuevas Guías de Rehabilitación Después de un EVC

🏃‍♂️Ejercicio
🧠Cognición y Comunicación
📉Prevención de Caídas
📱Tecnología y Telerehabilitación
🏠Regreso a la Comunidad

📖AHA/ASA 2026

Artículo Completo👇🏻✅🆓
https://t.co/aR5SFK2xfj

[Josh Farkas MD 💊 @PulmCrit]

I'm working on the RV failure chapter

is anyone using IV nitroglycerine infusions intentionally as a *pulmonary* vasodilator?

IV nitroglycerine is actually a reasonably good pulmonary vasodilator with a lot of parallels to IV milrinone or IV epoprostenol (physiology data review here: https://t.co/CHDFQUfPvi).

for a patient in RV failure who has a PA catheter en situ, trialing cautious up-titration of IV nitroglycerine gtt may sometimes be reasonable. It's a safe agent especially with invasive ICU-level monitoring. If it doesn't help, you can stop it and it will be gone in minutes. It may cause some mild systemic hypotension (like *any* IV pulmonary vasodilator).

Admittedly there isn't any high-level data for this, so it would be justifiable only if it had a positive impact on the patient's physiology (n=1 concept). (There also isn't any high-level data for *most* of what we do in RV failure).

It's kinda wild the way we usually ignore the effect of vasodilators on the pulmonary circulation. It is truly the forgotten side of the heart.

#ThePeoplesVentricle

[J. Roberto Mancilla 🧢 @JMancillaleon]

@NoticiasCaracol Dígale al juez que ordene suspender carros bombas donde pueda haber "ciertos indicios" que hayan niños .

[J. Roberto Mancilla 🧢 @JMancillaleon]

🤣🤣🤣🤣 capitán perico

[Chompos @ChomposX]

Es mi culpa, ahuyenté al capitán perico @petrogustavo 😕

[J. Roberto Mancilla 🧢 @JMancillaleon]

@transito_bga @Cportilla40 ahora a todo momento la carrera 27 y 33 colapsadas y no un agente visible. Ojala fueran trancones por obras pero ni eso. Que descalabro los últimos 4 gobiernos de la ciudad

[Jaime Arizabaleta @jarizabaletaf]

Los noto más indignados con la foto de Abelardo con bandidos dados de baja, que con los 18.887 niños reclutados.

Farsantes

[Piter Albeiro @PITERALBEIRO]

Un juez acaba de decirle a la guerrilla que la unica manera que se salven de un bombardeo del ejercito es que salgan a reclutar niños y tenerlos alla que son el escudo perfecto 😡😡😡 increible

[Ariel Ricardo Armel @arielarmelv]

Nueva definición de IPC:

“Impuesto al consumidor”

Lo de Mafe Carrascal no es normal…

[Leonardo Santos @Leo_Santo5]

🧂🚨Hipernatremia en el Paciente Grave? No Siempre Es Falta de Agua‼️

💧Déficit de Agua Libre
🧂Carga Oculta de Sodio
🚽Diuresis Osmótica
🩸Estado de Volumen
🧠Tratamiento Según la Causa

📖Intensive Care Medicine 2026

Artículo Completo👇🏻✅🆓
https://t.co/aR5SFK2xfj

[J. Roberto Mancilla 🧢 @JMancillaleon]

@MarianoVianci @MincomercioCo @MauricioGomezCO Jajajajajajajajajaja bodegas de izquierda con la orden de narrativa de comparar los actos religiosos, con la Virgen de los sicarios. 🤡🤡🤡🤡🤡

[J. Roberto Mancilla 🧢 @JMancillaleon]

@cielo_rusinque @anajimenabr 🤡🤡🤡🤡🤡🤡 con la minería ilegal de su jefe debieron morir muchos de esos animales.

[NEJM @NEJM]

Placement of a catheter for emergency peritoneal dialysis can be a relatively low-risk, low-cost procedure performed by a nephrologist at the bedside without the need for operating room resources. A minimally invasive insertion technique can allow peritoneal dialysis to be used as a suitable alternative to hemodialysis in patients requiring emergency kidney-replacement therapy.

For catheter insertion, begin by using the number 11 scalpel to create a transverse 2-cm incision approximately 1.5 cm deep along the midline. Use Kelly forceps to dissect down to the rectus muscle. This will help you advance the catheter toward the peritoneal space. The average length of the catheter used is 15 cm from the distal tip to the sphere. Patients with a larger body habitus and adipose tissue may require a longer length given the added distance required to reach the rectus muscle. This added length can be determined by inserting the Kelly forceps into the incision and measuring the distance between the rectus muscle and the skin surface. With the mobile sphere on the catheter positioned at the estimated depth for placement, insert the catheter and trocar into the incision site. If the patient is conscious and able to follow directions, ask the patient to lift the abdomen to provide countertraction for the trocar. Direct the catheter caudally at an angle of 60 to 80 degrees. Apply firm, constant pressure to the trocar. As the catheter enters the peritoneal space, you should feel and possibly hear one or two pops, and then the catheter should slide through without resistance. Once the catheter and trocar have been inserted to the appropriate depth, remove the trocar.

Learn more in “Placement of a Catheter for Acute Peritoneal Dialysis,” a Video in Clinical Medicine: https://t.co/lP3NN23Fiq

[Mauricio Ambriz @AmbrizMau]

En dos estudios de cohorte (con >7000 participantes) se encontró que acostarse a las 23:00 y despertar a las 07:00 marcó el menor riesgo de mortalidad. Dormir después de medianoche se asoció con hasta 53% más mortalidad por cualquier causa.

J Clin Sleep Med 2024;20(4):545–553.

[CardiovascularCorner @TrackYourHeart]

Echo From Scratch | Post #5

Resolution: How clearly can echocardiography distinguish structures?

Ultrasound resolution is not the same in every direction.

There are 3 dimensions of resolution:

1. Axial resolution
The ability to distinguish two structures along the direction of the ultrasound beam.

This is the most precise type of resolution.

It depends mainly on:
◻️Frequency
◻️Pulse length
◻️Bandwidth

Higher frequency means a shorter wavelength and generally better axial resolution.

For example:
3.5 MHz: approximately 1 mm
7.5 MHz: approximately 0.5 mm

Axial resolution is essentially independent of depth.

A wider bandwidth also improves axial resolution because it allows the system to generate shorter pulses.

2. Lateral resolution
The ability to distinguish structures side-by-side, perpendicular to the ultrasound beam.

Unlike axial resolution, lateral resolution changes with depth.

It is best where the ultrasound beam is narrowest, usually in the focal zone.

Beyond the focal zone, the beam diverges and lateral resolution worsens, producing increasing image blurring.

This is why correct focal-zone placement matters.

3. Elevational resolution
The ability to distinguish structures in the thickness of the imaging slice.

This is often overlooked because it is harder to appreciate on a 2D image.

The ultrasound beam has a finite thickness, typically around 3–10 mm in cardiac imaging.

Signals from structures just outside the intended imaging plane can therefore be included in the image.

This can create misleading findings.

For example, a calcified structure outside the imaging plane may appear as a linear structure within the aortic lumen and potentially mimic a dissection flap.

The key concept
- Axial resolution = along the beam
- Lateral resolution = side-to-side
- Elevational resolution = slice thickness

And remember:

Axial resolution is relatively independent of depth.

Lateral and elevational resolution are strongly affected by depth and focusing.

So when interpreting an echo, not every structure you see necessarily lies exactly where it appears on the screen.

Understanding the 3D shape of the ultrasound beam is essential for avoiding imaging artifacts and making accurate measurements.

[Simón Molina ♻️ @simonmolinag]

Entonces @cielo_rusinque se posesionó como magistrada del CNE y esa misma noche usó la foto oficial del juramento —bandera, mesa de Estado, firma presidencial— para decir que “el tigre se inclina ante el jaguar”.

Llegó al tribunal que vigila las elecciones a avisar que no vino a dar garantías, sino de MILITANTE?

Y lo hizo con los símbolos del cargo que juró respetar horas antes?

Si el primer acto público de una magistrada electoral es tratar de burlarse del presidente que la posesionó, entonces qué podemos esperar?