Will Ashley-Fenn

ICU JCF

[IMCrit @IM_Crit_]

#POCUS - New fear has been unlocked:

According to guidelines, chest tubes should be placed at the superior rib border to minimise risk of damage to the neurovascular bundle (which is shielded by the inferior rib edge). Adding Doppler to the pre-procedural ultrasound may identify

[IMCrit @IM_Crit_]

Clinical examination
- does not correlate well with cardiac output
- does not inform us reliably on the cause of tissue hypoperfusion
- does not help us decide what therapy to apply

https://t.co/V0cQwwdaiG

[IMCrit @IM_Crit_]

15 min video about how to perform #VExUS with @iceman_ex and Sam Orde @echonepean

https://t.co/OTFAD45sd3

#foamed #foamcc #meded #medtwitter #pocus #ECHOFIRST #POCUSpeeps #FOAMed #FOAMus #IMPOCUS #EMBound @curromir @MynephCC

[IMCrit @IM_Crit_]

I always say that even if a procedure (intubation, central line placement etc) looks easy and "straightforward", you never know what you are gonna face

[Cliff Reid @cliffreid]

Here’s how I think we often fail our patients when treating ’sepsis’

a 🧵

1/11

[nick pulmcrit @pulmtoilet]

What we should remember is “sepsis” by definition is not an oxygen DELIVERY issue; it’s an oxygen utilization issue —

Sure some patients could use fluid but remember that’s NOT the issue in sepsis

1. Get source control
2. Antibiotics early and the right ones
3. Do no harm

[Ross Prager @ross_prager]

@FH_Verbrugge discusses the top 10 diuretic mistakes at #HR24 .

If you prescribe lasix you need to read these key mistakes👇

10 Diuretic mistakes 🧵

#1: Not getting the job finished.. don't stop diuresis too early. If you fail to decongest, outcomes are worse and there is a higher risk of readmission to hospital.

#2: Being distracted by serum Creatinine.. rising Cr does NOT indicate dying kidneys!!

#3: Giving oral loop diuretics for in-hospital pts. with clear fluid overload (instead of IV diuretics)...

When dosing loop diuretics, there is a threshold effect that until above that you get no effect, and then a ceiling effect where any more diuretics don't increase diuresis.

#4: Underdosing (loop) diuretics and compensating with increasing maintenance outpatients doses instead.

Lasix dose = 1-2 times oral maintenance dose only makes sense IF the maintenance dose was appropriate... might not be the best place to start.

Does house of god (book) have it right? Adjust based on GFR. If you have poor kidney function need higher dosing... general gestalt
GFR>45 --> 80 IV lasix
GFR 30-45--> 120 IV lasix
GFR <30 -->120 IV lasix

#5: Too infrequent dosing of loop diuretics
LaSIX --> lasts six hours.
If you dose too infrequently then you get Na resorption in-between diuretic doses.
Start BID or TID with Lasix, not once daily! (sometimes even QID)

#6: Using loop diuretic drips (No lasix infusions!)
Higher plasma-renin activity with diuretic infusions...

#7: Failure to recognize fluid overload when cardiac filling pressures are normal / not terribly elevated

You can be overloaded with normal filling pressures. Volume does NOT equal pressure.

If overload + high filling pressures --> diurese fast

If overload + low filling pressures --> diurese slow

#8: Mistaking one size fits all for diuretic resistance
Steps to treat diuretic resistance:
1. Maximize Loop Diuretic
2. Add thiazide like diuretic (e.g Metolazone)
3. Add other nephro segment blocker (Acetazolamide, Spiro, Empagliflozin, Amiloride)
4. Consider hyperdiuresis (3% saline with diuretics)
5. Consider diuresis

#9: Don't be afraid of combination diuretic therapy
ADVOR trial: acetazolamide added to loop diuretic improved decongestion. We need to start thinking about multi-modal diuresis!

#10: Don't mistake decongestion for dehydration
Decongestion is about removing sodium.

Positive sodium balance with net fluid loss still portends worse survival (Hodson et al 2019).

#echofirst #Cardiology #medtwitter #foamed #foamcc #pocus #physiology

The key is in the pee
Check urine sodium concentration 1-2 hours post diuretic ... want a urine Na > 100 ideally (<80 is diuretic resistance)

[Josh Farkas MD 💊 @PulmCrit]

if you combine data from the DEFENDER and DARE-19 trials, dapagliflozin seems to cause a significant reduction in the initiation of hemodialysis in acutely unwell patients 👀
@f_g_zampieri #Flozinator

[IMCrit @IM_Crit_]

ICU scenarios (and pet peeves):

- Hey doc, this patient with ileus in bed 6 has a blood pressure of 186/68. What do you want me to give?
- Any worrisome symptoms with this BP?
- No, I am just worried she will stroke out
- Don't give anything
- No hydralazine then?
- No, please