KJ

[KJ @KJK0730]

@saikatmitra05 @IM_Crit_ @MegriMohammed @ArielG_RRT @emireles_c @OfVentilation I also don’t see an excessive amount of patient effort here. Usually see this flow pattern with high elastance lungs, simply cannot distend any further and pressures equilibrate quickly. I would drop the I-time and see if that helps

[KJ @KJK0730]

@saikatmitra05 @IM_Crit_ @MegriMohammed @ArielG_RRT @emireles_c @OfVentilation You have a corresponding period of 0-flow or equilibrated pressures on both your 2nd and 3rd waveforms, implying your applied pressure is no longer contributing to more volume (flat on baseline in 2, flat portion in 3)

[KJ @KJK0730]

@JonahRubinMD Thank you Dr. Rubin I have frequently referenced this series to my CCM colleagues looking to advance themselves in echocardiography and was always disappointed when it had fallen off YouTube. Thanks again

[KJ @KJK0730]

@Askins_Razor @nickmmark @CritCareTime You gentlemen are on FIRE lately

[KJ @KJK0730]

@msiuba @UMdPCCM Will this be recorded or available somewhere??

[KJ @KJK0730]

@IM_Crit_ I feel like I have seen things like this before however in the OR; perhaps some sort of issue with insufflation of the abdomen? Feels vagal-ish to me

[KJ @KJK0730]

@DrToddLee @BradSpellberg @MedFactChecks @BJegorovic @IM_Crit_ Do one of you mind linking a quality negative study or two against tamiflu? I admit the paper being discussed in this thread was incredibly unsatisfying however this winter I’d like some more ammo in my anti-Tamiflu arsenal despite just “the smart Twitter ID guys said so”

[KJ @KJK0730]

@CritCareTime hey gents, any thoughts on doing an episode on approach to fever in the ICU? Feel like this is glossed over a lot and would love to hear y’all talk chat it in a thoughtful manner (plus it gives Nick an excuse to use fancy words like “antipyretics” and “defervesce”)

[KJ @KJK0730]

@msiuba This is brilliant, I’m sure I speak for the masses when I say thank you et al

[KJ @KJK0730]

@pulmtoilet @heart_lung @IM_Crit_ @msiuba @PulmCrit @PulmPEEPs @EMNerd_ @emily_fri @ThinkingCC @icmteaching @AZviman @nickmmark @CriticalCareNow Quite a bit of Ea (>> Ees?) for an LV in such bad shape regardless of RV performance

[KJ @KJK0730]

@nickmmark I was waiting for a really terrible punchline but something tells me this is a legitimate question

[KJ @KJK0730]

@nickmmark @CritCareTime You and @Askins_Razor have until 6:15am EST tomorrow or my Pi-Day morning commute will be RUINED

[KJ @KJK0730]

@msiuba I can commiserate, I’m a PGY-3 and probably took until the middle of my 2nd year to rid myself of the very monosynaptic “cirrhosis + AKI = initiate HRS protocol” line of reasoning. The circulatory physiology (and variability) in patients with liver disease is quite daunting

[KJ @KJK0730]

@msiuba Outstanding. And last one, am I correct to assume hepatic dysfunction was the inciting insult here, leading to progressive and perpetuating cardiac / RV dysfunction? Or is the physiology too deranged to delineate chicken from egg at this stage

[KJ @KJK0730]

@msiuba Ah yes, just saw your “HRS” reply elsewhere; feel like lately a majority of severely congested VeXUS waveforms have been associated with severe TR, it’s nice to see a relatively aesthetic CVP waveform like this reminding us of other pathologies. How is this pt doing?

[KJ @KJK0730]

@msiuba Would be very curious to see VeXUS waveforms associated with this CVP waveform

[KJ @KJK0730]

@MegriMohammed 3) would also consider the possibility of additional diuretic (after optimizing vasoactives) such as acetazolamide or thiazide-type, I imagine your UNa is suboptimal even with those doses of furosemide; consider intrinsic loop resistance on top of poor perfusion

[KJ @KJK0730]

@MegriMohammed 2) dobutamine and milrinone are perhaps more arrhythmogenic than Epinephrine (perhaps low dose, 0.05?) + vasopressin, this combo may be more beneficial here plus some afterload reduction if tolerated (likely would be)

[KJ @KJK0730]

@MegriMohammed 1) Seems like a scenario where your NE (particularly at high dose) may be harmful to CO as a result of increasing SVR > CO (uncoupling the LV); with a map of only 60 and this much congestion I can’t imagine your renal perfusion is optimal

[KJ @KJK0730]

@PulmCrit 😍😍