Discover and read the best of Twitter Threads about #VExUS

Most recents (24)

A tale of two hearts: Physiological observations on AV shunts and congestion 🧵

These are 2 patients on IHD I saw in the outpatient clinic

🔷 Both with severe venous congestion (#VExUS = 3)
🔷 Both with tortuous brachiocephalic AV fístula

1/11 Image
What I found remarkable was the diametrically opposed effects of manual AVF compression on JVP! 🤯

🔴 Patient A: AVF Compression improves venous congestion
🔵 Patient B: AVF Compression worsens venous congestion

🔴 Patient A: SLE + Lupus Nefritis ➡️ ESRD in HD

#echofirst: Plethoric IVC, good LVEF, paradoxical septal motion, ventricular interdependence, severe RV/RA dilation, torrential TR

Read 11 tweets
Pt w right HF and high probability pulmonary hypertension

TAPSE 15 mm, TRVmax 4.1 m/s, paradoxical septal motion

Renal Venous Doppler 👇

According to…, Which curve color would best describe this patient's PH-related morbidity?

Poll and 🧵👇

1/6 ImageImage
Which curve in the Kaplan Meier Curve above best fits this particular patient?

The Renal Doppler shown 👆 looks like a biphasic pattern. This would mean the green curve 🟢

However there is a catch.....

3/6 Image
Read 6 tweets
One of my favorite and most intriguing causes of severe venous congestion (#VExUS = 3)

A 🧵on High Output Heart Failure (HOHF) 1/18
First, the index case:

Clip above shows hyperdynamic flow from the vena cava

#echofirst 👇: Very dilated and plethoric IVC, LV OK, Dilated RV, D sign

Overall: Increased Right heart filling pressures

IVC = 3.4 cm
Portal Vein = > 100% pulsatility
TRVmax = 3.04 m/s

So we have:

Venous Congestion (IVC, Portal Vein)
High Cardiac Output (LVOT-VTI)
Pulmonary Hypertension (TRVmax)

Read 18 tweets
En nuestros #SabadosdePOCUS tuvimos a @ACRP901 con el tema:

"Los Secretos Ecográficos de la Vena Cava Inferior (#VCI/#IVC)"

¿Quieres enterarte de alguna puntos claves?

Abrimos hilo... 🧵 #POCUS
Un punto clave del Dr. @ACRP901: "Los niños no son adultos pequeños"
La VCI sigue siendo esquiva.
Es #Fundamental conocer la fisiología y anatomía al tocar este tema.
Y recuerda: los secretos se encontrarán en la #Fisiología más que en la ecografía per se.
La #VCI se encuentra inmersa en varios protocolos y en las modificaciones de cada uno de estos dependiendo el contexto del paciente (#FOCUS, #RUSH, #EFAST).

Se habían utilizado a la #VCI regularmente para medir el estado de volemia y una posible respuesta (o no) a fluidos.
Read 25 tweets

👴 w Advanced Cirrhosis, hemorrhagic portal hypertension and hx of a heart block (w pacemaker).

Came to the ED w diarrhea 2/2 severe C. Diff.

Now in shock...

Initial resus with Norepinephrine 0.3 ug/kg/min, Crystalloid and albumin. Cr 3.8

18 hrs later, no renal improvement + oliguria.

MABP 70, CRT 2 seconds. 🧠 confused, + asterixis. No ascites or edema

Workup: hemodynamic AKI (⬆️SG, ⬇️UNa, ⬆️BUN/Cr, bland sediment)

Team wants to continue fluids, albumin and antibiotics... Dr. Harris, do you concur?

Obviously you are here for the #POCUS so here we go:

IVC: Plethoric (No subX window 2/2 intestinal air)
LV, RV: Relatively preserved systolic fx
Pacemaker lead seen causing important Tricuspid Regurgitation!

Read 7 tweets
#Nephrology #POCUS short story:
1/ Simple case, want to remind some pitfalls in routine practice.
There was a patient with orthostatic hypotension. Likely neurogenic secondary to amyloidosis.
Read the thread 🧵below:
#IMPOCUS #MedEd mini #tweetorial
2/ Physician A orders IV albumin q 6 hours and keeps continuing because:
1. 'Formal' echo from 4 days ago reported a RAP of 3 mmHg = not high
2. 'Documented' weight showed 3 kg drop since admission
Interestingly, documented cumulative fluid balance is +4 L!
3/ Physician B comes in and performs physical examination (#POCUS). Supine BP is relatively low (SBP ~103 mmHg) but nothing different compared to patient-reported figures at home. Pt feels OK, on midodrine.
Here is the IVC👇
Read 9 tweets
Time to discuss some rationale/evidence behind doing #VExUS #POCUS #Nephrology
A short #tweetorial #MedEd 👇
1/ Is fluid overload harmful?
of course yes. Here is a recent meta-analysis.
2/ Does fluid administration affect renal venous flow in asymptomatic but vulnerable patients (#heartfailure)?
3/ In fact, elevated CVP is associated with reduced GFR.
This 👇is a study in outpatients undergoing right heart cath (N = 2557). In CVP values >6 mm Hg, a steep decrease in GFR was observed.
Read 18 tweets
#POCUS #echofirst #MedEd case of the day.
Context: alcoholic liver cirrhosis with suspected #hepatorenal syndrome
Purpose: think about the underlying pathophysiology & seek expert input
1/ PLAX, PSAX, Apical views of the heart. Heart rate ~110-116 bpm
#VExUS images in 🧵
2/ overall, looks hyperdynamic. LA looks little enlarged on PLAX, visual TAPSE high on apical.
In cirrhosis, hyperdynamic circulation is expected because of splanchnic vasodilatation and 'relative' arterial under filling.
LV EF #POCUS obtained using @kosmosplatform 👇
3/ Lets calculate stroke volume using LVOT VTI #POCUS
It looks supra-normal
Read 20 tweets
OK #VExUS #POCUS enthusiasts, time for another case discussion.
Somebody asked if I ever recommend IV fluid in a patient with #VExUS 3.
Here is one example where I did.
1/ First, let's see the #physicalexam (#IMPOCUS) findings, then will tell about the case. #MedEd #Nephrology
2/ So, hepatic shows D-only pattern👆
If we are doing #VExUS, IVC must be big. Here is the M-mode #POCUS 👇
3/ Renal parenchymal vein #VExUS #POCUS
It also demonstrates D-only pattern 👇
Read 15 tweets
Time for a #POCUS #tweetorial on optimization of Doppler. Very important for #VExUS enthusiasts. #MedEd
1/ Unlike greyscale imaging which depends on amplitude of the returned signal, Doppler depends on frequency information. This graphic explains why perpendicular angle is bad.
2/ other way of saying this, in relevance to color Doppler #POCUS
RBC moving away from the probe = Fr<Ft = negative Doppler shift = Blue color
RBC moving towards = Fr>Ft = positive Doppler shift = Red color
Rest of the images/videos from this excellent paper:…
3/ Anatomy (components) of a spectral Doppler waveform (carotid shown)👇
Above baseline is like red on color (towards probe), below = blue. As 0 degree angle is not always possible, <60 is considered OK.
Read 19 tweets
1/ Thought of doing a quick #tweetorial on image acquisition for #POCUS friends starting to do #VExUS
It's kind of "how I do it" guide and not necessarily optimized for research.
1st: Look at the IVC in both long and short axes
If big, do further scans 👇 #MedEd #FOAMed
2/ Lateral approach works best to obtain a straight segment of the portal vein (straight = best Doppler shift) and a nice hepatic vein too.
Place transducer approximately in the anterior axillary line pointing towards sternal notch. Then fan antero-posteriorly.
3/ Forgot what is fanning?
Its also called tilting or some people say, "look" in a particular direction from the same spot.
Read 18 tweets
Patient in Janus Jeneral Hospital with neutropenic septic shock. 3ml/hr of single strength noradrenaline - MAP 65, FiO2 30%, Lactate 7. CVP 5. UO 50ml/hr. CTPA negative for PE. AP4C on arrival. #vexus #echo #shock #FOAMed @GUH_ICU_Anaesth @IrishEMtrainees @ICSIreland
Has already had 3L of crystalloid pre admit to crit care.

RVSP = TR Max PG (18.4) + CVP (5) = 23mmHg
Overnight, lacto-bolo reflex sets in & gets 'maintenance' plus multiple boli of IV crystalloid b/c of high lactate.

In the am, increasing shocked state. On norad 20ml/hr SS, vasopressin max, adrenaline 5ml/hr to maintain MAP > 60.

RV & RA acutely dilated on focused US.
Read 7 tweets
OK #VExUS #POCUS hemodynamicians, welcome back to the case. As promised, here are some follow up images:
@ArgaizR @ThinkingCC @khaycock2 @katiewiskar @Thind888 @MDBeni et al.
Hepatic v. 👇
Looks D-only but could this be S-wave? (or a delayed D? Pt has Afib and predisposed to having smaller S but wondering if there is some S-D fusion here)
Forgot, here is the IVC. Similar to previous.
Read 13 tweets
#Nephrology consult for worsening creatinine in the context of diuresis in a patient with #heartfailure
Documented weight 3 kg ⬇️ than the previous day. No accurate urine output. Pt feels OK (has some unrelated issue).
Question: over diuresis?
#POCUS #MedEd #VExUS see thread 👇
So, there is decreased LV systolic function and obviously diastolic dysfunction. Bi atrial enlargement. No significant pericardial effusion (there was trace on PLAX).
Next step in the hemodynamic circuit #POCUS assessment?
btw repeat weight was similar.
Next: IVC #POCUS assessment to assess right atrial pressure.
Here it is 👇
Big and plethoric (take it as 15 mmHg in a spontaneously breathing person - we get RVSP of ~41 mmHg based on the above tricuspid gradient)
Read 10 tweets
All nephrologists should be learning #POCUS now. It is safe, reproducible, cheap!!! Some uses are:
1. Rule out obstruction
2. Dx cause of hemodynamic inestability
3. To guide vascular access

@WBeaubien #KidneyWk
Beyon the basic applications in #AKI
1. Assessment of kidney perfussion
2. Detection of early AKI
3. Prediction ofpersistent AKI
4. Detect kidney congestion

2D US is ok, but using other modalities like doppler we can get more granular data on kidney hemodynamics.

However using only color doppler or power doppler is not good enough. #KidneyWk
Read 9 tweets
Elderly ♂️, PMH of T2DM and CKD.

Suspected COVID-19 because of shortness of breath. Sent to the COVID-19 ED service.

No fever, no cough. No chest pain. Physical exam with patient sitting up (almost 90°):

¿Is this neck pulse arterial or venous? 1/8
Pulse is diffuse and the most striking feature is inward movement. I borrowed this table from @AndreMansoor's must-see lecture on Jugular Venous Pulse **Curiously, notice that there is a single peak instead of the expected double peak 🤔 2/8
I had to get my probe! #POCUS showed severely reduced EF with anterior wall motion abnormality and normal RV function.

EKG showed anterior ST segment changes. This was ACS! Cath lab was activated

Read 8 tweets
Tired of irradiating your patients with CT scans🙋‍♀️? Learn Renal Ultrasound #POCUS!

1⃣Perform Renal Ultrasound
2⃣Download Hydronephrosis PDF Guide!
3⃣Renal Pathology
4⃣Renal Hemodynamics (RRI/Venous Doppler)

✅New Blog Post! 👉🔗

#medtweetorial (1/25)👇
1 Download the FREE Hydronephrosis Grading PDF Pocket Guide! 👉🔗
2 The kidneys are retroperitoneal organs located on either side of the vertebral column from T12-L3. Notice that the right kidney is slightly more posterior than the left kidney because of the larger size of the liver relative to the spleen. 👉🔗
Read 26 tweets
Understanding #VExUS from scratch:
A mini #tweetorial on normal hepatic vein waveform genesis 👇 #MedEd #echofirst

1/ Understanding color and direction
2/ What is S wave? #POCUS
3/ V wave #POCUS
Read 8 tweets
#POCUS Intra-renal vein Doppler waveform looking exactly like that of hepatic vein!
#VExUS obtained from a #nephrology clinic patient with pulmonary hypertension. #MedEd
Normal hepatic vein waveform #POCUS Image
Portal vein #POCUS in this patient - increased pulsatility. Image
Read 6 tweets
Pitfalls of #VExUS venous waveforms by @WBeaubien #HRreloaded 2020
Improvement of Portal Vein Pulsatility with CRRT fluid removal.

Possible use to predict Intra-dialytic hypotension? @NephroP
Read 3 tweets
Journal Club in the time of COVID 🤓🩺😷

@ubcimpocus had our inaugural #POCUS journal club with our fellow @teres_sono (welcome to #MedTwitter Terry!!).

The topic was all things #VEXUS and some really great questions came up (1/)
Note COVID modifications:

- small group, all seated 6ft apart
- masks, wipes, hand sanitizer easily accessible
- no shares food; individual drinks (yes, gasp, alcohol - #professionalism)
- Zoom mtg on individual devices to enable distanced screen sharing
Many questions came up, both technical and philosophical:

- When scanning the hepatic vein, does it matter which branch (L/mid/R) you scan? (My answer: I scan whichever gives me the best waveform (3/)
Read 9 tweets


Kidney Replacement Therapy #KRT & #AKI

One ring to rule them all
To this day: NO difference in outcomes between

- Difussion vs Convection
- Std vs ⬆️ dose
- Early vs Late ⏰

The problem is #AKI & what it represents. #KRT can’t change that, no matter how you do it

💥SOLUTE & VOLUME control💥
becomes the only GOAL

1. Nutrition 🥩
2. Potassium 🍌
3. Acid base 🧪
4. Phosphorus 🦴
5. Fluid balance 💧
Read 15 tweets
(1/ )There has been an overwhelming interest in the use of hepatic waveforms as a congestive parameter. With social media, somewhat obscure concepts like these are quickly brought to the forefront and implemented in clinical practice. Many are eager to incorporate #VEXUS but...
...a thorough understanding of these waveforms, hemodynamic correlates, and dynamic changes that occur in physiology and disease, is paramount to incorporating this into practice. #shocksquad #tweetorial #VEXUS #showmethewaveform. Here are rules of interpreting hepatic waveforms
(2/13)Rule 1: **Nomenclature, nomenclature, nomenclature! **
That’s right! For us to understand each other we must speak the same language. I have heard these waves being described in a multitude of ways which has brought about considerable confusion and miscommunication.
Read 16 tweets
Session IV ft @ThinkingCC @aron_jonny @drhazemlashin
➡️ Hemodynamics, RV and #VEXUS #covid19pocus
Early phase = predicted fluid responsive state
RV struggles at an early stage as result of hyperinflammatory lung condition - moderate dilation, increase in TRVmax, worsening RV strain pattern
Read 19 tweets

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