This is my first critical care echo case tweetorial. I will be discussing the assessment of potential fluid responsiveness in critical care. Case today, answers tomorrow.
Please do give me honest feedback so I can make these useful.
The case is a post-op patient who is hypotensive. They have had some fluid resuscitation already. Do they need more filling? Do they need inotropes? Do they need vasopressors?
They are intubated and fully ventilated.
Here is the PLAX.
And here is the A4C.
Thinking specifically about potential fluid responsiveness: 1. You increase the TV on the ventilator to 8ml/kg. 2. The patient is fully ventilated, with no spontaneous breaths.
Here is the VTI variation at the LVOT.
The variation is 7%.
You perform a passive leg raise (PLR), and then repeat the LVOT VTI assessment.
So here are the VTIs post-PLR.
The average VTI has gone from 21.35 in the last image (pre-PLR) to 20.55 now (post-PLR). Pretty much no change.
A patient with long-standing renal failure has a cardiac arrest on commencement of dialysis. You achieve ROSC, and do a focused echo. Here are the views you achieve.
Parasternal long axis...
Thank you to everyone who commented and voted on this case - some great debates!
Before I go through assessment of fluid responsiveness in critical care, it's worth saying that it is one component of your overall assessment of the patient. Not to be taken in isolation. [1/12]
One of the key principles here is that the positive pressure delivered into the thorax from the ventilator will affect the venous return to the right heart (with less returning during inspiration).
This leads to variation in IVC and LVOT VTI/V max values.
[2/12]
Some variation is completely normal.
But when patients are hypovolaemic, they are more susceptible to the pressure changes, & the variation will get larger.
In ICU we can also see this as "swing" on an arterial line trace
It is not so simple in a spont breathing patient
[3/12]
1. A person has mild Covid infection and isolates at home for 10 days. They go back to work and are fine. A week later they are killed crossing the road.
This IS counted as a death from Coronavirus.
[2/4]
2. A person has severe Covid infection and spends over a month in ITU. They get weaker, and get other chest infections, while in hospital. Ultimately they fail to recover and die.
This is NOT counted as a death caused by Coronavirus.
[3/4]
As lockdown restrictions are being lifted, it’s tempting to think that life can start to get back to normal. I think it’s key to understand how hospitals have changed to cope with COVID-19 and how rushing to normality is causing much apprehension for the many health workers [1/8]
Even before the #COVIDー19 pandemic, ITUs were typically short staffed and running at almost full capacity.
This relied on all medical team members working incredibly hard together, along with goodwill overtime, to ensure safe staffing levels. [2/8]
To cope with the surge in #COVIDー19 cases, hospitals cancelled most elective operations.
This led to more beds being available, and medical and nursing staff were redeployed in order to provide care for the sickest people in our new expanded intensive care areas. [3/8]
Organ donation in the UK has now changed to an "Opt-out" system.
What does this mean for you and your family?
Bear with me, and I will briefly go through the changes, and how you can ensure you can communicate your wishes, even if it is too hard to talk to your family. [1/n]
Death and dying are very hard subjects to talk about, and often make people feel uncomfortable. However, at some stage we will all die, and it’s worth thinking in advance what we would want at that point in our lives - and ideally communicating that to those close to us. [2/n]
Sometimes, death may occur in a way that means the body organs (e.g. kidneys, lungs) would not be significantly injured, and could potentially be donated to someone else who might really benefit. [3/n]
With more people being offered testing for Coronavirus, daily updates on numbers tested, and potential news in the bid for an accurate antibody test, it’s a good time for an overview on testing. A thread. [1/n]
There are two broad types of test:
1. Those looking for antigen (i.e. you currently have Covid) 2. Those looking for antibodies (i.e. your immune system has faced Covid recently). [2/n]
Antigen tests need a respiratory sample, the vast majority of which are nasopharyngeal or oropharyngeal swabs (or both). This means a sample taken from far back in your nose or mouth.