Back on COVID-19 service this month

Went to see this patient with "increased respiratory drive despite high dose sedation and NMB". This is the vent: 1/4
Looking at the patient's monitor, the respiratory curve seems oddly coincident with heart rate: 2/4
Inspiratory pause reveals NO respiratory drive and several cardiogenic oscillations! 3/4
Trigger was 3.0 l/min so I increased it to 6 l/min. Afterwards I was able to stop NMB and lower sedation.

Diagnosis: Auto Triggering (triggering secondary to cardiogenic oscillations) 4/4

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More from @ArgaizR

6 Oct
A case for hepatic vein Doppler lovers:

ECG tracing not abvailable on the ultrasound machine (I tried, I swear)

Can we still interpret this HV waveform without ECG?

I speculate we can!

I'll try to do it step by step: 1/7 Image
What can we tell?

For one, there are 2 retrograde waves and 1 antegrade wave.

Given the patient was in sinus rhythm, then one of the retrograde waves MUST be an A wave! 2/7 ImageImage
Given HV waveform sequence should always be A-S-D, AND A wave is always retrograde:

Then this leaves only 2 possibilities: There could either be S wave reversal or D wave reversal 3/7 ImageImage
Read 8 tweets
14 May
🧵 AKI and #COVID19

68 yo ♂️ PMH obesity, HTN, CAD w stent, OSA, T2DM
➡️ ED w SOB + fever 39.9°C. Poor oral intake

RR 40, Sat 94% Room Air, BP 157/74 HR 124. Alert. Bibasilar crackles

Labs: Cr 1.3 (baseline 0.8), WBC 10, K 5.4, HCO3 17, CK 184. UA and CXR👇 (case from @NEJM)
How would you manage this AKI initially? What is the likely cause of AKI in patients with #COVID19? (this last question discussed in thread 🧵)
No easy answer except to say that FENa is very unlikely to be useful. It is not unreasonable to try fluids for AKI in the setting of perceived hypovolemia. However, this gets complicated when the potential for worsening ARDS exists. I'll try to tackle the answers one by one 💪
Read 17 tweets
11 May
Which of these patients has a more severe degree of venous congestion? #VExUS Thread 🧵 about the Portal Vein (1/17)
Video above shows IVC in short axis, long axis and diameter (from left to right)

Which of these patients has a more severe degree of venous congestion? (2/17)
Abdominal IVC size depends on the difference between CVP and IAP. At a constant IAP, IVC size will increase proportionally to CVP until it reaches the flat part of it's compliance curve. (Great thread by @Thind888 here: ) (3/17)
Read 18 tweets
28 Apr
Dr. Gattinoni or: How I Learned to Stop Worrying about P-SILI and Love Furosemide

WEIRD THREAD 🧵 About the blood-gas barrier and #COVID19 (1/9)
Clinical Case: A 4 year old Thoroughbred Horse with a history of recurrent racing-associated epistaxis comes to your office complaining of decreased track performance. He wants to know if there is anyway to prevent this from happening (2/9)
What treatment would you recommend? (3/9)
Read 10 tweets
22 Apr
“If you think an awake patient having normal mental status and a basic metabolic panel is available needs a blood gas, you’re wrong. You need the blood gas done on yourself because you may be brain dead.” quote from Dr. Corey Slovis (1/7)
A few days ago I ran this poll. Most of you chose not to get an ABG. This is in fact what I did (and disappointed the consulting team) Pt had no comorbidities, and HCO3 was normal. (2/7)
Pt not on opioids and no COPD should have a preserved respiratory drive, thus hypercapnia should NOT occur unless exhaustion. Instead, I monitored my pt closely and that same evening O2sat much better. A few days later pt was discharged home. Not a single ABG was drawn. (3/7)
Read 7 tweets
18 Apr
"Dry (#COVID19) lungs are happy lungs." This is the last line of this thoughtful piece on @MGHMedicine's FLARE:… Well balanced concerns with fluid loading vs aggressive diuresis. I'd like to add some thoughts.... (1/13)
Goal is euvolemia (Duh?). Easy to say but, WTH is euvolemia anyway?. Let's be honest, fluid therapy has always been about keeping the kidneys happy. Two examples of this #nephrocentric approach to fluids (one from FLARE, one from @jlvincen) (2/13)
Non of this is wrong. Definitely hypovolemic patients (vomiting, diarrhea, and poor oral intake) will benefit from fluids. However, the emphasis of fluid therapy tailored to creatinine ignores that most Sepsis-induced AKI is NOT VOLUME RELATED! (3/13)
Read 14 tweets

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