Robert Inga

Médico Emergenciologo en Perú Hospital Dos de Mayo Aprendiendo POCUS

[Robert Inga @Robertinga]

@Manifest_Lord H

[PAUSE @PAUSEHNDM2023]

Colocación de vía periférica ECOGUIADA por la licenciada Cecilia . La importancia de capacitar tanto a licenciados como médicos en ecografía : mejora la atención al paciente #POCUS #nurse #emergency @ondasPOCUS @AngelFarro1

[PAUSE @PAUSEHNDM2023]

Hoy recibimos la grata visita del Maestro Dr Arun Nagdev 🇺🇸 Gracias por las enseñanzas !

[Dr. AK 🇮🇳 @docakx]

💥Smith 𝘦𝘵 𝘢𝘭. reported draining a world record of 41 𝗹𝗶𝘁𝗿𝗲𝘀 of ascitic fluid in a single paracentesis session of a patient with decompensated cirrhosis.

How much Albumin would be needed in this case to prevent post paracentesis circulatory dysfunction ? 🧵 Read on👇

A 🧵 on important points to consider while performing Large Volume Paracentesis (LVP)

𝘏𝘰𝘸 𝘮𝘶𝘤𝘩 𝘢𝘭𝘣𝘶𝘮𝘪𝘯 𝘪𝘴 𝘵𝘰 𝘣𝘦 𝘪𝘯𝘧𝘶𝘴𝘦𝘥 𝘥𝘶𝘳𝘪𝘯𝘨 𝘱𝘦𝘳𝘧𝘰𝘳𝘮𝘪𝘯𝘨 𝘓𝘝𝘗❓️

𝘞𝘩𝘢𝘵 𝘪𝘴 𝘵𝘩𝘦 𝘮𝘢𝘹𝘪𝘮𝘶𝘮 𝘢𝘮𝘰𝘶𝘯𝘵 𝘰𝘧 𝘢𝘴𝘤𝘪𝘵𝘪𝘤 𝘧𝘭𝘶𝘪𝘥 𝘵𝘩𝘢𝘵 𝘤𝘢𝘯 𝘣𝘦 𝘥𝘳𝘢𝘪𝘯𝘦𝘥❓️

🛑Large Volume Paracentesis(LVP)
is arbitrarily defined as a paracentesis with >5 L of ascitic fluid drained.

In patients undergoing LVP, the use of albumin is crucial to prevent a further reduction of effective arterial blood volume, which may precipitate postparacentesis circulatory dysfunction (PPCD).

The clinical manifestations of PPCD include renal impairment, including HRS, dilutional hyponatremia, hepatic encephalopathy and death.

Albumin infusion is particularly important if more than 5 L of ascites are removed to prevent the development of PPCD.

Paracenteses of a smaller volume(<5L) are not associated with significant hemodynamic changes and albumin infusion may not be required.

Although there has not been a dose‐response study on albumin use with LVP, the administration of 6‐8 g of albumin per liter of ascites removed has been recommended.

💥For example, after the fifth liter, approximately 40 g of albumin should be infused, and after 8 L removal, the amount of albumin given should be approximately 64 g.

It has been held that there is no limit for the amount of ascites that can be removed in a single session, provided an appropriate amount of albumin is administered.

However, the risk of PPCD increases with >8 L of fluid evacuated in one single session.

A study showed that by limiting the LVP volume to <8 L per session and providing a higher than recommended dose of albumin (9.0 ± 2.5 g per liter of ascites removed), renal function and survival may be better preserved over a mean period of 2 years despite the development of PPCD in 40% of patients.

In patients with hemodynamic instability (systolic blood pressure <90 mm Hg), hyponatremia (serum sodium <130 mmol/L), and/or the presence of AKI, albumin infusion should be strongly considered for paracentesis of a smaller volume.

LVP is a safe procedure even in the presence of coagulopathy. In a study that included patients with an international normalized ratio of >1.5 and a platelet count of <50 × 109/L, only 1% of patients experienced minimal cutaneous bleeding after LVP.

Therefore, elevated prothrombin time or thrombocytopenia is not a contraindication for paracentesis, nor is transfusion of clotting factors or platelets recommended.

Possible exceptions may include patients with disseminated intravascular coagulation or uremia with thrombocytopenia.

1/3 👇 𝘾𝙤𝙣𝙩.

#MedTwitter #MedEd #MedX

[Critical Care Time @CritCareTime]

NEW Critical Care Time episode about pleural physiology &amp; pneumothorax (PTX)!
-what do the pleura do (bonus: why 🦬 &amp;🐘 pleura are special)
-types of PTX (spontaneous, etc)
-how to use POCUS to diagnose PTX
-treatment: observation, N2 washout, small &amp; large bore chest tubes

1/

[Joaquin Cordero @JocorderoV]

Mujer 61a. Tras discusión inicia dolor precordial intenso. Imágenes : acinecia medioapical. Dx: Síndrome de Takotsubo 😑 #POCUS @ondasPOCUS @AngelFarro1 @Robertinga @DreyfussAndrea @ericabr09 @perezni46 @2000mhMari @acisneros389 @coreultrasound @EMRAPGO

[Joaquin Cordero @JocorderoV]

Vesícula Biliar : Signo de WES (Wall Echo Shadow) . (A) Vista Longitudinal (B) Vista Transversal #POCUS #emergency @ondasPOCUS @DreyfussAndrea @Dmartin07EM @AngelFarro1 @Robertinga @perezni46 @2000mhMari @acisneros389

[RutgersNJMS_POCUS @RutgersPOCUS]

Identify SBO at bedside (curvilinear probe):
- 3+ fluid-filled loops of bowel w/ &gt;2.5 cm diameter
- "To-and-Fro" movement of bowel content/ decreased/ absent peristalsis
- Thickened bowel wall &gt; 3mm
- Free fluid between loops of bowel (higher grade obstruction, poorer prognosis)

[The Innovation | Medicine @Innov_Medicine]

Blood: Who can receive what blood type
#MedEd #MedTwitter

[Joaquin Cordero @JocorderoV]

Mujer 64a. Dolor abdominal persistente. La importancia de realizar un diagnóstico oportuno de patologías con alta tasa de mortalidad : Aneurisma Aorta Abdominal Complicado #POCUS @ondasPOCUS @DreyfussAndrea @AngelFarro1 @EMRAPGO @Robertinga @perezni46 @acisneros389 @UPAndo6

[Angel Farro 🇵🇪 @AngelFarro1]

Rotación de Ultrasonido para Residentes de Medicina de Emergencias y Desastres en el Hospital Dos de Mayo. Vamos avanzando en el desarrollo de nuestra especialidad. Esperamos que más residentes de provincia se animen a venir. El equipos del HNDM los espera @Robertinga @vaguers1

[Angel Farro 🇵🇪 @AngelFarro1]

Curso Taller de POCUS/UPA en el Hospital Dos de Mayo para asistentes y residentes del Hospital María Auxiliadora. Seguimos avanzando 💪 @DreyfussAndrea @Dmartin07EM @Robertinga @vaguers1 @physicianSEM @JocorderoV @LazaroNury @JackelineEstof1 @italo05airway @2000mhMari @perezni46

[POCUS Certification Academy @POCUSAcademy]

(1/2)
A 38-year-old female presented with pain in the right upper abdomen. The following two images were obtained while scanning her gallbladder. What is the most likely diagnosis?

A. Acute cholecystitis
B. Acute Gangrenous cholecystitis
C. Emphysematous cholecystitis

[Joaquin Cordero @JocorderoV]

Varón57a. Acude por tumefacción en región perineal + fiebre + signos de hipoperfusión . Clip 1 :signos de abscesos con aire . Clip 2 ,3 : testículos con presencia de aire . Paciente rumbo a SOP #POCUS @DreyfussAndrea @Dmartin07EM @Robertinga @AngelFarro1 @5MinSono

[Joaquin Cordero @JocorderoV]

Mujer46a. Acude por dolor agudo en cuello y tórax . Se aprecia FLAP de disección en ventana supraesternal , paraesternal eje largo y en apical 4 cámaras #POCUS @DreyfussAndrea @Dmartin07EM @AngelFarro1 @Robertinga @2000mhMari @LazaroNury @vaguers1 @UPAndo6 @ondasPOCUS @5MinSono

[Joaquin Cordero @JocorderoV]

Mujer 69a. Acude con clínica abdominal inespecífica desde hace 1 mes . AAA con Trombo intramural #POCUS @ondasPOCUS @PhilipsLumify @5MinSono @DreyfussAndrea @Dmartin07EM @LazaroNury @2000mhMari @perezni46 @vaguers1 @Robertinga @AngelFarro1

[Joaquin Cordero @JocorderoV]

Woman 58y. Abdominal pain and fever for 2 weeks.Heterogeneous echogenicity with defined borders in liver. Liver abscess #POCUS @DreyfussAndrea @Dmartin07EM @AngelFarro1 @Robertinga @vaguers1 @2000mhMari @perezni46 @ondasPOCUS @PhilipsLumify @5MinSono

[Joaquin Cordero @JocorderoV]

Paciente varón 77a acude por epigastralgia y sincope. AAA con presencia de trombo intramural #POCUS @DreyfussAndrea @Dmartin07EM @ondasPOCUS @PhilipsLumify @perezni46 @2000mhMari @AngelFarro1 @Robertinga @LazaroNury @vaguers1

[Italo VÁSQUEZ Vargas @physicianSEM]

#UPA Recibiendo a los rotantes. Este mes un subespecialista de pediatría y nuestro 1er extranjero (Mexico). Bien trabajo Dra Jacky Estofanero. Seguimos avanzando. @ondasPOCUS @JackelineEstof1 @AngelFarro1 @italo05airway @DreyfussAndrea @Dmartin07EM @UPAndo6

[Lourdes Perez Abad @perezni46]

Alerta 🚨 @litolobo @saludconlupa