Thread by @iceman_ex

Good morning everyone! For my first session of day 2, I’ve decided to come and learn all about vasculitis in the ICU - being presented by Marlies Ostermann from @GSTT_ICU #lives2018

Marlies starts with a couple of case histories:

Middle aged women, presenting with undifferentiated pulmonary and renal failure, raised inflammatory markers, Nonspecific chest X-ray changes...

But which one has vasculitis? #lives2018

The answers are surprising...

(And it looks like you should #POCUS everyone with suspected vasculitis 😁😜) #lives2018

So what is vasculitis? It’s an inflammation of blood vessel walls #lives2018

How is it classified? #lives2018

(Also see this from @precordialthump lifeinthefastlane.com/ccc/polyangiit… #foamed #foamcc)

This is a great slide showing the current pathophysiology of vasculitis #lives2018

So the antibodies we test for (peri nuclear or cytoplasmic Antineutrophilic cytoplasmic antibody) can help in diagnosis- but they aren’t perfect... #lives2018

There are 3 other types of vasculitis:
- immune mediated
- Anti GBM
-Drug induced
#lives2018

The rash can present in lots of different ways...

And the histological appearance of necrosis you see on skin biopsy can also appear in Sepsis. Be warned #lives2018

Vasculitis is a multisystem disorder #lives2018

Polyarteritis Nodosa is a specific vasculitis which leads to multiple aneurysms #lives2018

Lung vasculitis can present...

However it likes really 😕#lives2018

Vasculitis in the nervous system can present with mononeuritis multiplex- or disorders if conscious level, up to and including seizures

This slide shows blood vessels pre and post treatment. It makes a massive difference #lives2018

Can you predict the presence of vasculitis based on the organs involved?

If you can you’re a legend because I can’t #lives2018

So vasculitis can present like EVERYTHING ELSE WE SEE IN ICU #lives2018

So what should you do?

-high index of suspicion
-biopsy something
#lives2018

And how should we manage it?

-organ support
-remove the circulating antibodies
-prevent new antibodies from being formed

Simples! #lives2018

Rituximab seems to work really well for vasculitis

nejm.org/doi/full/10.10…

nejm.org/doi/full/10.10…

#lives2018

What are the outcomes in the ICU?

Series from 2016: ncbi.nlm.nih.gov/m/pubmed/26812…

ICU Mortality 16%
90 day mortality 18% #lives2018

Future challenges... #lives2018

Summary slide on Vasculitis!

My take homes:
-high index of suspicion
-let’s attack aggressively (a prize to anyone who gets the random video game reference)

#lives2018

Ok #pocus tweeps:

There are NO STUDIES on POCUS in vasculitis.

Could it have a role? Could there be vascular patterns that we could pick up, and some kind of score? #lives2018

Marlies reckons that the disease is too variable to be consistently images though.