👴 w Advanced Cirrhosis, hemorrhagic portal hypertension and hx of a heart block (w pacemaker).

Came to the ED w diarrhea 2/2 severe C. Diff.

Now in shock...

Initial resus with Norepinephrine 0.3 ug/kg/min, Crystalloid and albumin. Cr 3.8

18 hrs later, no renal improvement + oliguria.

MABP 70, CRT 2 seconds. 🧠 confused, + asterixis. No ascites or edema

Workup: hemodynamic AKI (⬆️SG, ⬇️UNa, ⬆️BUN/Cr, bland sediment)

Team wants to continue fluids, albumin and antibiotics... Dr. Harris, do you concur?

Obviously you are here for the #POCUS so here we go:

IVC: Plethoric (No subX window 2/2 intestinal air)
LV, RV: Relatively preserved systolic fx
Pacemaker lead seen causing important Tricuspid Regurgitation!

LVOT-VTI = 21 (Normal stroke volume)

Hepatic Vein = S reversal (severe TR)
Portal Vein = Pt had portal vein thrombosis. No flow seen
Intra-Renal Vein Doppler (IRVD) = Monophasic "D" only

#VExUS = 3

TRVmax = 3.53 m/s (high probability PH)

There is relatively preserved systolic fx

There is also venous congestion (Plethoric IVC)

But #VExUS tells me more: It tells me congestion is severe enough to be transmitted to the kidney!

There is a high chance this is congestive AKI!
(AKA intra-capsular tamponade)

I recommended stopping albumin and fluids. Multi-agent diuresis (High dose Furosemide + Spironolactone) and continue Vasopressor

It worked! Pt had excellent urine output, negative fluid balance and 3 days later Cr returned to baseline 0.9 mg/dl 😎

Low kidney perfusion in Cirrhosis can be 2/2 hipovolemia, vasodilation, abdominal hypertension, congestion, low CO....

Are you seriously going to keep calling all of these "low effective arterial blood volume"?

Dominate hemodynamics, #POCUS Always!


• • •

Missing some Tweet in this thread? You can try to force a refresh

Keep Current with Eduardo R Argaiz

Eduardo R Argaiz Profile picture

Stay in touch and get notified when new unrolls are available from this author!

Read all threads

This Thread may be Removed Anytime!


Twitter may remove this content at anytime! Save it as PDF for later use!

Try unrolling a thread yourself!

how to unroll video
  1. Follow @ThreadReaderApp to mention us!

  2. From a Twitter thread mention us with a keyword "unroll"
@threadreaderapp unroll

Practice here first or read more on our help page!

More from @ArgaizR

3 May
AKI Consult: 👵 ➡️ ED with severe DKA. CT Abdomen and Chest to look for infectious trigger: negative. Tx with IV insulin and balanced crystalloid + 6 L with obvious improvement. Cr was 2.7

Remained oliguric, now in sudden shock with increasing NE dose (0.5 ucg/kg/min) 🚨 1/12
#POCUS Very hyper-dynamic🫀 with increased contractility and no RV dysfunction.

🔎 Look carefully at color of flow exiting the LV:

Aliasing (green color): This means ultrasound system is trying to image an event that is occurring faster than the sample rate

This means flow is fast. But how fast? Choose the CW doppler setting and find out!

In this case acceleration was almost 6 m/s!

Flow acceleration occurs in the setting of obstruction (similar to putting your finger on the hose exit)

So what is causing the obstruction? 3/12
Read 12 tweets
16 Feb
Pt w advanced liver cirrhosis. 🏥 Comes w worsening ascites. No fever🤒, no bleeding🩸. 🧠 ok, no asterixis. BP 91/50. Labs📈: AKI (Cr 3.0 mg/dl), UNa 7 mEq/L, bland sediment. #POCUS 👉small cirrhotic liver with significant ascites. Paracentesis ruled out PBE. 📊Poll below👇 1/11
What would your initial treatment be? 2/11
Don't treat reflexively. A thorough physical exam ♥️🩺revealed a systolic murmur at left lower sternal border. Neck exam 👇

Sitting Down (90º) /// Supine (45º) 3/11
Read 11 tweets
10 Feb
📞 Nurse: Patient has a blood pressure of 226/118 mmHg!
📞 Resident: Nifedipine 30 mg STAT!
📞 Me: About that last call, please hold Nifedipine until we assess the patient

A 🧵of some cases of Inpatient Hypertension 👇 1/15
🔎🖥️..This was a pt w ARDS on IMV. Other vitals 🆗. Previous BP= normal, no recent change in sedation, vent 🆗, no asynchronies. UOP = 0 for 2 hrs 🤔. Exam: Distended bladder!

After foley catheter change, BP normalised 😎

Why do we have this reflex to treat acute high BP? 2/15
A big component is the perceived expectation that we must do something! (In our minds, Are we trying to prevent organ injury?)

A great example can be seen here 👇 3/15

Read 15 tweets
16 Oct 20
Elderly ♂️, PMH of T2DM and CKD.

Suspected COVID-19 because of shortness of breath. Sent to the COVID-19 ED service.

No fever, no cough. No chest pain. Physical exam with patient sitting up (almost 90°):

¿Is this neck pulse arterial or venous? 1/8
Pulse is diffuse and the most striking feature is inward movement. I borrowed this table from @AndreMansoor's must-see lecture on Jugular Venous Pulse **Curiously, notice that there is a single peak instead of the expected double peak 🤔 2/8
I had to get my probe! #POCUS showed severely reduced EF with anterior wall motion abnormality and normal RV function.

EKG showed anterior ST segment changes. This was ACS! Cath lab was activated

Read 8 tweets
6 Oct 20
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
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
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
Read 8 tweets
5 Oct 20
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
Read 4 tweets

Did Thread Reader help you today?

Support us! We are indie developers!

This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Too expensive? Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal Become our Patreon

Thank you for your support!

Follow Us on Twitter!