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.
You have a look at the IVC.

Variation of 9%.
So, what do you think? Please vote below.

Answers tomorrow!
Forgot to tag anyone in this - schoolboy error.

So...
@nat_echo @cardiacLucy @dr_benoy_n_shah @DrDanAugustine @vitormweaverBSE @samjc1976 @PetermoranPeter @scrivsy85

Please feel free to re-tweet and share. This is pretty frequent query on ITU.

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More from @GoughCJ

16 Sep
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]
Read 13 tweets
27 Mar
I am getting asked a lot what it’s like working in Intensive Care at the moment. I think the best way to answer is with an overview of a recent shift.

It’s all a bit unsettling. We need extra staff on so I’ve been moved from days on to nights. [1/n]
We’ve moved handover to a bigger room in an attempt to try and stay a bit away from each other.

After handover it’s hard to differentiate the patients. They all have such similar stories...a few day history of cough and fevers. [2/n]
We have 1 bay of suspected Covid-19 cases and 2 bays of confirmed ones.

The ventilated patients become a bit static. It is several days before they can breathe strongly enough for themselves, with good enough oxygen levels, to be ready to come off the ventilator. [3/n]
Read 12 tweets
16 Mar
Now that I am recovering from Covid-19, I want to share my symptoms, and my experience, in case it is of help to anyone else. I've felt pretty rotten the last few days, but am finally improving.

I am only talking about my own experiences - as a patient, not a doctor. (1/n)
I'll have a quick moan about testing, and then go through my symptoms.

Testing, testing, testing.
We must stop the ridiculous imbalance where politicians and sports stars can apparently get tested, but frontline health workers cannot. The criteria must be consistent. (2/n)
Symptoms.

D1: The day of fevers and exhaustion.

Shivers and sweats were the story of the day. That and being utterly exhausted, with whole-body ache. Random temp: 38.5. One flight of stairs then stop for a rest. No appetite at all. (3/n)
Read 10 tweets

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