Eduardo R Argaiz Profile picture
Internist | Nephrology Fellow @incmnszmx | #DiuresisJedi #POCUS #VExUS

3 May, 12 tweets

AKI Consult: 👵 ➡️ ED with severe DKA. CT Abdomen and Chest to look for infectious trigger: negative. Tx with IV insulin and balanced crystalloid + 6 L with obvious improvement. Cr was 2.7

Remained oliguric, now in sudden shock with increasing NE dose (0.5 ucg/kg/min) 🚨 1/12

#POCUS Very hyper-dynamic🫀 with increased contractility and no RV dysfunction.

🔎 Look carefully at color of flow exiting the LV:

Aliasing (green color): This means ultrasound system is trying to image an event that is occurring faster than the sample rate

2/12

This means flow is fast. But how fast? Choose the CW doppler setting and find out!

In this case acceleration was almost 6 m/s!

Flow acceleration occurs in the setting of obstruction (similar to putting your finger on the hose exit)

So what is causing the obstruction? 3/12

Aortic stenosis is one possibility, if you look at #POCUS 👆 aortic valve looks normal.

In the setting of a hyper-dynamic LV, Dynamic Obstruction of the Left Ventricular Outflow Tract (DOLVOT) should be the first thing that comes to mind!

4/12

journals.sagepub.com/doi/10.1177/03…

DOLVOT can occur suddenly whenever there is
🚨Decreased LV filling volume🚨

Predisposing mechanisms:

Asymmetric septal hypertrophy
Sigmoid septum
Motion wall abnormalities (including 🐙)
Systolic anterior motion of the mitral valve (SAM)

5/12

atsjournals.org/doi/10.1513/An…

Decreased LV filling is always secondary to any of this three variables:

⬇️ Preload: Hypovolemia, Obstruction (RV failure w interdependence)

⬆️ Contractility and Heart Rate: Beta agonist, Norepinephrine

⬇️ Afterload: Sepsis

6/12

As such, treatment should focus on:

⬆️ Preload: Fluids.

*sometimes this is enough if the cause is hypovolemia (attached case)

⬆️ Afterload: Alfa agonists with no inotropism

⬇️ Contractility and heart rate: Beta Blockers

7/12

In this case, even though cause was not clear, I started fluid bolus and stopped NE.

Then...the patient had abundant GI bleeding 🩸🩸🩸

We aggressively resuscitated with fluid and blood products. Patient improved immediately 8/12

However, one hour later we were back at square one:

Patient was in shock again!

Did patient need more fluid? I performed #LUS: Clear B-lines. Even thought patient is still fluid responsive. She is no longer fluid tolerant!!!

I was not keen on continuing fluids... 9/12

I ordered AngioCT to rule out active recurrent bleeding.

No bleeding.

However diverticulitis with abscess formation was diagnosed!!

Not previously seen because of lack of IV contrast 🤦‍♂️
10/12

We started antibiotics and vasopressin (⬆️ afterload with no inotropism). *IV beta-blocker was not available at the moment (public hospital shortage).

Fortunately, vasopressin did the trick and patient improved and oliguria resolved! Repeat #POCUS showed DLVOTO resolution 11/12

🔑
💎DLVOTO is easy to diagnose (CW Doppler)
💎Norepinephrine should be avoided at all costs
💎Although these patients improve rapidly with fluid,
THIS IS NOT A PERMANENT SOLUTION
💎Treat with Phenylephrine + IV BB

Bonus: Always use IV contrast even in AKI! @PulmCrit

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