OK #VExUS#POCUS enthusiasts, time for another case discussion.
Somebody asked if I ever recommend IV fluid in a patient with #VExUS 3.
Here is one example where I did. 1/ First, let's see the #physicalexam (#IMPOCUS) findings, then will tell about the case. #MedEd#Nephrology
2/ So, hepatic shows D-only pattern👆
If we are doing #VExUS, IVC must be big. Here is the M-mode #POCUS 👇
3/ Renal parenchymal vein #VExUS#POCUS
It also demonstrates D-only pattern 👇
4/ D-only is severe congestion but its 👆better than the recent D-only we saw in a hyponatremic patient👇 Remember? (better in terms of how much cardiac cycle has venous flow) #POCUS
5/ So, by definition, its already #VExUS grade 3 because 2 of the 3 veins we evaluate demonstrate severe flow changes.
6/ Are you expecting that portal will be 100% pulsatile?
Here it is...surprise!👇
7/ This patient has h/o pulmonary hypertension. Remember, we discussed that hepatic and renal veins might never be normal in such cases but portal can normalize & helps when there is superimposed fluid overload?!
8/ Now, a few pictures of the pump.
RVOT Doppler #POCUS
V-shape is a little abnormal but no prominent notching appreciated unlike a recent case where I showed the 'W-pattern'
10/ Quick look at the left heart filling pressures using mitral inflow Doppler #POCUS and lateral annulus tissue Doppler.
E-wave deceleration time seems normal (an indicator of PCWP)
11/ Lateral e'
12/ Lung #POCUS predominantly A-lines with B-lines in basal zones associated with irregular pleura. Likely chronic changes.
So why fluids and what's the clinical context?
13/ Patient had AKI, likely secondary to ATN. While the serum creatinine is improving, developed post-ATN diuresis with an UO of ~5L in 24-hours.
Also had worsening hypernatremia with a calculated free water deficit of ~2 L + metabolic alkalosis.
14/ My recommendation was to give Half NS to replace at least half of the UO over the next 24 hours. Chloride containing fluid also helps with alkalosis.
That's it! I don't prefer free water 'flushes' through NG tube when significant amount of water has to be replaced.
#POCUS#echofirst#MedEd case of the day.
Context: alcoholic liver cirrhosis with suspected #hepatorenal syndrome
Purpose: think about the underlying pathophysiology & seek expert input 1/ PLAX, PSAX, Apical views of the heart. Heart rate ~110-116 bpm #VExUS images in 🧵
2/ overall, looks hyperdynamic. LA looks little enlarged on PLAX, visual TAPSE high on apical.
In cirrhosis, hyperdynamic circulation is expected because of splanchnic vasodilatation and 'relative' arterial under filling.
LV EF #POCUS obtained using @kosmosplatform 👇
3/ Lets calculate stroke volume using LVOT VTI #POCUS
It looks supra-normal
#POCUS quiz of the day:
Easy one. Identify 1, 2 and 3.
POLL in thread 👇 #IMPOCUS#MedEd
👆#POCUS
PE = pleural effusion
PER = pericardial effusion
Ao = aorta
IVC = inferior vena cava
Rt = right
Lt = left
Correct answer: option 2 - 1. left pleural effusion (note the appearance of collapsed lung; also u can see rib shadows/posterior chest wall = lung area) 2. Right pleural effusion (remember the Boomerang sign on subxiphoid view?) 3. IVC
Time for a #POCUS#tweetorial on optimization of Doppler. Very important for #VExUS enthusiasts. #MedEd 1/ Unlike greyscale imaging which depends on amplitude of the returned signal, Doppler depends on frequency information. This graphic explains why perpendicular angle is bad.
2/ other way of saying this, in relevance to color Doppler #POCUS
RBC moving away from the probe = Fr<Ft = negative Doppler shift = Blue color
RBC moving towards = Fr>Ft = positive Doppler shift = Red color
Rest of the images/videos from this excellent paper: pubs.rsna.org/doi/10.1148/rg… 3/ Anatomy (components) of a spectral Doppler waveform (carotid shown)👇
Above baseline is like red on color (towards probe), below = blue. As 0 degree angle is not always possible, <60 is considered OK.
@khaycock2@ArgaizR@katiewiskar@ThinkingCC
Any comments on this portal vein pulsatility obtained from a pt with cirrhosis? (Why prox is more pulsatile?)
No cardiac issue that I know of; was reviewing rad-performed images 🤔
Splenic seems to be fine, looks more like that of distal portal.
1/ Thought of doing a quick #tweetorial on image acquisition for #POCUS friends starting to do #VExUS
It's kind of "how I do it" guide and not necessarily optimized for research.
1st: Look at the IVC in both long and short axes
If big, do further scans 👇 #MedEd#FOAMed
2/ Lateral approach works best to obtain a straight segment of the portal vein (straight = best Doppler shift) and a nice hepatic vein too.
Place transducer approximately in the anterior axillary line pointing towards sternal notch. Then fan antero-posteriorly. #POCUS#VExUS
3/ Forgot what is fanning?
Its also called tilting or some people say, "look" in a particular direction from the same spot. #POCUS
#Nephrology#POCUS case of the day:
What do you think is this anechoic structure adjacent to liver?
See thread 👇 for the answer and more images. #MedEd#IMPOCUS
Let's start with a poll before seeing other images: ☝️? #POCUS
The answer is right renal cyst. Note how the kidney appears with fanning the probe. #POCUS
Is rest of the kidney normal? doesn't appear to be...🤔