Mátyás Andorka

consultant in ICM&anaesth.; POCUS: FAMUS+FUSIC supervisor, FUSIC heart, CACTUS lung mentor; regional anaesth.; airway lead; retired ATLS/ETC/ALS/GIC instructor

[Mátyás Andorka @easypocus]

some says #POCUS answers (to the basic #FICE #CUSIC #FAMUS questions) are binary: yes/no.
but imo there must be 3:
- yes
- no
- i don’t know

3rd is not cool, but absolutely valid and most importantly: safe

[Prof. Feynman @ProfFeynman]

We need to teach how doubt is not to be feared but welcomed. It's OK to say, "I don't know."

[Difficult Airway Society (DAS) Residents @dasresidents]

A star studded session this afternoon on aspiration, TIVA and RSI with Prof El-Boghdadly, DAS President Prof Al McNarry and SIVA president Dr Alistair Baxter
@elboghdadly
@altgm
@SIVAnaesthesia
@SIVATrainees
@dasairway
#DASWales2026

[𝘈𝘯𝘢𝘦𝘴𝘵𝘩𝘦𝘴𝘪𝘢 @Anaes_Journal]

Rapid sequence induction

There is insufficient evidence for many of the elements of RSI to determine whether they reduce patient harm or to state confidently that they do not.

@doctimcook @altgm

#AnSky #MedX #MedTwitter

https://t.co/KWapu6ge9z

[NephroPOCUS @NephroP]

Periodic reminder.
#POCUS #echofirst #Nephpearls

[Josh Farkas MD 💊 @PulmCrit]

I just updated the IBCC chapter on pulmonary vasodilators, here are new pearls I learned 🤯

🫁 The dosing of inhaled pulmonary vasodilators is a little different for ARDS versus for treatment of RV failure. In ARDS, you're shooting for selective vasodilation of the best-ventilated alveoli to maximize V-Q matching, so you want a mid-range dose (too high and you start vasodilating the worse-ventilated alveoli). In RV failure you're trying to vasodilate every alveoli as much as possible to bring down the pulmonary vascular resistance, so go high.

🫁 Nebulized milrinone causes selective pulmonary vasodilation for ~20-30 minutes, then gets systemically absorbed. One dose of nebulized milrinone in the OR is great, but scheduling milrinone nebs q4hr doesn't make pharmacological sense (it doesn't achieve consistent pulmonary vasodilation and there are risks of systemic accumulation in renal failure). IMHO milrinone nebs don't have much role in ICU. If you want to give milrinone just give it IV.

🫁 There's a gradually escalating amount of evidence supporting combined simultaneous use of inhaled epoprostenol and inhaled NO to treat RV failure. See the article by Andre Denault below. This may be a good option for RV failure before escalating to an Impella RP Flex. It's pretty easy to trial a patient on inhaled pulmonary vasodilators - if they work great, if they don't work you haven't lost much.

#1/2, link in next post.

[Ashley Miller @icmteaching]

Voting for @ICS_updates council members is now open. My very good friend Jennie Stephens is running. I’ve worked with her in various ICS capacities for many years now and I can’t think of anyone who would be a better council member. She will be brilliant if elected. Please consider voting for her if you are an ICS member.

[#hello my name is Ross @ffolliet]

The signal to noise ratio describes the strength of a desired information signal against the level of unwanted background signal. How easy is it for the audience to clearly determine the message of a presentation.

Please read, comment and RT https://t.co/IASRWNbFhr

[ANDROMEDA-SHOCK @AndromedaShock]

All the hot topics in septic shock resuscitation with the ANDROMEDA-SHOCK- NETWORK at full throttle; First World Summit! 53 faculties. Our next research projects discussed at length. Registration open, full programme (QR). Bidirectional translation. Videos available 6months

[Tim Cook @doctimcook]

Pleased to see this published

NARRATIVE REVIEW OF RSI

Loads of information & we hope a good overview

The topic is very controversial, sadly sometimes driven by not being up to dare with the existing evidence.

Feel free to read, discuss & dispute!

https://t.co/i0aWjaMkeR

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

🧠 ❤️ Is a normal blood pressure enough to guarantee cerebral perfusion? The emerging role of transcranial Doppler

In acute brain injury, we frequently target mean arterial pressure (MAP) and cerebral perfusion pressure (CPP) using predefined thresholds.

However, CPP = MAP -ICP does not tell us whether cerebral blood flow is adequate.

Cerebral perfusion also depends on vascular resistance, autoregulation, cardiac output and arterial CO₂.

This article by Melo and Robba explores how transcranial Doppler (TCD) could help individualize blood pressure targets at the bedside.

The key is understanding the Doppler waveform.

Diastolic flow velocity (FVd) reflects forward flow during diastole and is sensitive to downstream perfusion conditions.

The pulsatility index (PI) reflects the interaction between pulsatile inflow and distal cerebrovascular resistance.

A low FVd with elevated PI may suggest increased downstream resistance or reduced perfusion pressure.

However, PI is not a direct measurement of ICP, and TCD velocity is not equivalent to volumetric cerebral blood flow.

What happens when we increase MAP?

Consider a patient with traumatic brain injury, MAP 67 mmHg, FVd 14 cm/s and PI 1.5.

After norepinephrine titration:

At MAP 77 mmHg, FVd increases to 19 cm/s and PI decreases to 1.2.

At MAP 83 mmHg, FVd reaches 23 cm/s and PI falls to 1.0.

Further MAP augmentation produces little additional improvement.

This illustrative case demonstrates a physiological principle: the optimal pressure may be the range where cerebral flow dynamics become more favorable, not simply the highest achievable MAP.

Yet interpretation requires caution.

Increasing FVd during MAP augmentation may indicate pressure-dependent circulation with impaired autoregulation. Minimal changes may indicate preserved autoregulation or already adequate perfusion.

The systemic circulation cannot be ignored.

A low FVd does not automatically justify more vasopressors.

If cardiac output is reduced, fluid responsiveness is present, or severe hypovolemia exists, the underlying hemodynamic mechanism must be addressed.

Conversely, additional fluids in an unresponsive, congested patient may worsen cerebral edema or pulmonary dysfunction without improving cerebral perfusion.

TCD should therefore complement echocardiography, cardiac output assessment, ICP, brain oxygenation and neurological evaluation.

The important limitation: Doppler-guided pressure targeting remains physiologically promising but lacks robust trials demonstrating improved clinical outcomes.

Reference 📚
Melo RH, Robba C. 2026. Critical Care. https://t.co/6oWhuEEeKN

#NeurocriticalCare #TranscranialDoppler #CerebralPerfusion #Hemodynamics #CriticalCare

[Javier Teigell @javiteigell]

🛑 ¡No pinches este derrame!

Parece fácil: grande, varios espacios intercostales… pero hay una fina capa de pulmón atelectásico adherida a toda la pared. Una punción convencional atravesaría parénquima.

¿Lo habrías visto? 👇

#InternistaIntervencionista

[Cliff Reid @cliffreid]

Early bird extended! 🧙‍♂️

Resuscitation Wizardry, 7–8 Dec in London: two days of case-based resus, from airway, shock and neuroprotection through to how to make things happen when the system is working against you.

£330 early bird now runs until 7 Nov (then £385).

🎟️ https://t.co/ngor1IkBIZ

[Mátyás Andorka @easypocus]

#FUSIC HD

[Rafael Melo @intensivaev]

I measured the RV VTI during an incremental increase in PEEP.

[Manni Waraich @ManniWaraich]

https://t.co/jlOH7MCxvd

[Jeff Gadsden @jeffgadsden]

@amit_pawa @RegionalAnaesUK @DrRobbieErskine @HouthoffKavita @shanercpower @maffygirl @Wilkinsonjonny @curromir @KalagaraHari @NaveenEipe If you're not familiar with the costoclavicular block, here's a video that outlines the anatomy, how to do it, and some helpful tips... #Blocktober26

https://t.co/rpQAb8rkc4

[Cliff Reid @cliffreid]

40 places gone in the first three weeks for Resuscitation Wizardry London, 7-8 December

Two days on the clinical craft of resuscitation and the human factors that make it happen

£330 until 31 October

Please send this to one friend who loves resus: https://t.co/ys0a9boFXh

[Ross Prager @ross_prager]

Being "intravascularly dry" is often suspected when:

1. Furosemide monotherapy for diuresis is used, which produces metabolic alkalosis and hypernatremia irrespective of someone's true volume status.

2. Low MSFP shock due to vasoplegia in conditions like sepsis. The issue isn't about volume, but rather the pressure driving venous return.

3. Oliguria in the ICU. Many cases are 1) not AKI 2) not fluid responsive and 3) congestive

4. The patient has intracavitary gradients or dynamic LVOTo. These patients behave "super dry" . Preload helps temporarily, but afterload, beta blockade etc. accomplishes same goal in more durable fashion.

5. Pancreatitis patients. These patients have third spacing, sure, but actually are often more distributive. They require some fluids, but routine use of 100+ml/hr IV fluids in the absence of objective markers of low stroke volume and fluid responsiveness leads to many of the iatrogenic complications of pancreatitis we see!

[Mátyás Andorka @easypocus]

@doctimcook @mfettiplace @KalagaraHari @NicholasChrimes @AirwayMxAcademy @dasairway @jducanto @Siva6faces @SreeHPraveenKO1 @Ropivacaine @basemcc @msiuba @pritanand @noolslucas I guess channelled blade (or a modification of it to support the bougie)

[Difficult Airway Society (DAS) Residents @dasresidents]

🚆 Heading to DAS Wales 2026? Save with special Great Western Railway fares to Newport!

Join us at ICC Wales, 11–13 November, to shape the future of airway management.

Register now and secure your place! Plan your journey: https://t.co/v3Dz9rREkq
#DAS2026

[Mátyás Andorka @easypocus]

@jeffgadsden @AirwayMxAcademy @amit_pawa @EMARIANOMD @elboghdadly @RegionalAnaesUK @docmorne @DrJeniMD @EngySaid_MD @ajrmacfarlane @galusweegie @Nadia_Hdz_MD @michyaries888 @pritanand @BlockIt_Hot_Pod @deepak_neuro @rosie_hogg @DrNavSidhu @NavBahal @PeterMerjavy @DrRobbieErskine @DrTuhinM I have got slight flashbacks from DL/VL debates - although there will always be early adopters and fierce sceptics; time (and evidence) will tell…

COI: I’m very much in favour of #POCUS in general. I use gastric US in some cases.

[Jeff Gadsden @jeffgadsden]

@amit_pawa @EMARIANOMD @elboghdadly @RegionalAnaesUK @docmorne @DrJeniMD @EngySaid_MD @ajrmacfarlane @galusweegie @Nadia_Hdz_MD @michyaries888 @pritanand @BlockIt_Hot_Pod @deepak_neuro @rosie_hogg @DrNavSidhu @NavBahal @PeterMerjavy @DrRobbieErskine @DrTuhinM Gastric POCUS is an easy skill to learn and has definitely changed my management on a weekly basis. If you're unfamiliar with it, grab yourself a coffee and spend 9 minutes watching this: #Blocktober26

https://t.co/rPUuernqkL