Thread by @msiuba

Time for a new concept: a #zentensivist case report!

A middle aged woman with PMH of HTN is brought to the ED complaining of dysuria, decreased urination, and malaise.

She is hypotensive with MAPs in the 40s initially and receives 4L normal saline with improvement in MAP. 1/x

She is admitted to ICU. Dx: septic shock, UTI. You are seeing her 10 hr later.

(Borrowed #ogitorial format)
A ok
B mild⬆️WOB, home CPAP
♥️ MAP 66 no pressor
D avPu
E oliguric (<10 ml/hr)
U Preserved LV/RV fxn
L creat 5.9 from 0.9, UA: pyuria

RN alerts you to the low urine output on evening rounds. What’s your next step?

You just read ANDROMEDA-SHOCK and are intrigued by cap refill assessment, so you bought some microscope slides.

Cap refill time is 5 sec.

https://twitter.com/glennguru1/status/1200376326278066176?s=21

https://twitter.com/glennguru1/status/1200376326278066176

Now what?

It’s reasonable to assess fluid responsiveness. We did not! This patient was 10 hours from initial resus. Likelihood of response as per ANDROMEDA SHOCK very low. See this graph from the supplement.
Ref jamanetwork.com/journals/jama/…
Meanwhile, RN says “nephrology wants NS at 150/hr”

What do you do?

This patient had chronic HTN, on 3 agents for control. We raised her MAP goal (to 75) as per the protocol

Over the shift , urine output increases to 50, then 75, then 100 per hour!

Urine output maintains over the next few days with the higher MAP goal, Klebsiella was cultured and treated. By day 5, creatinine is near normal!

Herein lies the #zentensivist approach: fully attentive, minimally invasive. After initial #POCUS assessment, no tech was necessary!