Post

How to get URL link on X (Twitter) App

On the Twitter thread, click on or icon on the bottom
Click again on or Share Via icon
Click on Copy Link to Tweet
Paste it above and click "Unroll Thread"!
More info at Twitter Help

Mourad H Senussi, MD, MS

@msenussiMD

Oct 25, 2021 • 14 tweets • 4 min read • Read on X

Scrolly

** Bubbles of Truth **

We can gain a tremendous amount of clinical information by observing the flow of bubbles within our vascular system.

Here are a few illustrative examples!

Exhibit A:
Below is a subxiphoid view highlighting markedly distended hepatic veins and IVC. Note the reflux of bubbles into the HV/IVC consistent with high right sided filling pressures.

The bubbles in the above case are arising from rapidly infusing IV fluids through an upper extremity central venous catheter.

Why the reflux, you say?
Marked dilation of RA/RV with a hyperdynamic LV consistent with RV failure!

Exhibit B:
Utilize your bubbles to help localize (a) venous structures and (b) central catheter tip location.

How? Agitated bubbles can be injected via upper extremity CVCs to localize the catheter tip and observing for chamber quantification!

*Tip*
When attempting subclavian/axillary vein cannulations use a preexisting ipsilateral peripheral IV to inject agitated saline and localize bubbles within the subclavian vein to make double sure you aren't targeting the artery.

Voila! Longitudinal view of axillary/subclavian vein whilst flushing an ipsilateral peripheral IV. Proceed to cannulate with confidence.

Exhibit C:
Be wary of the patient with shock/resp failure and an abundance of bubbles opacifying the right heart.

Air embolism should be a careful consideration. Although it usually occurs upon removal of the catheter with rapid decompensation..I've seen cases while in situ!

Exhibit D:
Agitated saline for intra and extra cardiac shunting with provocative maneuvers and/or preexisting pulmonary hypertension
1. Atrial septal defects
2. Ventricular septal defects
3. Intrapulmonary shunting
4. Patent ductus arteriosus
5. Persistent L SVC

For an amazing in depth review
Check out the review article by Bernard et al "Agitated Saline Contrast Echocardiography in the Identification of Intra and Extracardiac Shunts: Connecting the Dots." JASE 2020

Exhibit E:
Bubbles in the portal vein can be an ominous sign indicative of GI tract infection/inflammation.

In this example, the patient has the double whammy. Portal vein bubbles and systolic flow reversal in hepatic veins due to right sided heart failure!

In conclusion, Be one with the bubble and follow the bubble for it reveals much about flow in our vascular system.

Uses
1. Assess congestion
2. Intra and Extra cardiac shunting
3. Line placement
4. Gas forming organism /GI tract woes

Any other uses..Oh, Twitterverse?

• • •

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

This Thread may be Removed Anytime!

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

More from @msenussiMD

Mourad H Senussi, MD, MS

@msenussiMD

Feb 8, 2023

**Hepatic Veins : A window to the heart**
What do you see here?

Clue: look at the rhythm

Hepatic veins can provide a plethora of information on the "right heart apparatus".
1. Tricuspid valve
2. RV function /PA pressures
3. Volume status

Often overlooked but can also glean some info on electrical activity of the atria i.e. atrial dysrhythmias.

Lets go over circuitous methods of doing so :)

Note good antegrade flow.

But one can clearly see the f-waves from the atrial flutter!

Read 7 tweets

Mourad H Senussi, MD, MS

@msenussiMD

Feb 7, 2023

***Bloodless central venous cannulation***
1. Preload the needle with your guidewire
2. Use wrap around technique to control the wire
3. Impeccable DYNAMIC ultrasound guidance
4. Rejoice - not a single drop of blood in your field

Alternatively can use the back end of specially designed needles that obviate the need to remove your syringe from the needle. I find it more cumbersome but allows for aspiration of blood!

Important caveats

Must use impeccable dynamic dynamic ultrasound technique and localize the needle tip intraluminally!

Most times when needle tip position is lost is during the syringe removal process. So try out this technique!

Read 4 tweets

Mourad H Senussi, MD, MS

@msenussiMD

Oct 16, 2021

*Hyperdynamic LV: Harbinger of Doom*

This clincial scenario has played out before my eyes on multiple occasions

Echo performed on a pt with undifferentiated shock

"EF > 70%...hyperdynamic.. all good."

A hyperdynamic LV is more sinister than you may think. Lets find out why..

Consider why the LV would be hypercontractile and avoid the knee jerk reflex to assume that it is ONLY due to hypovolemia/hemorrhage i.e decreased RV preload/low mean systemic filling pressure .

Start thinking in terms of LV preload.
1. RV failure
2. Mitral regurgitation
3. VSD
4. Vasodilated state

You need to actively rule out these conditions in the right clinical context.

Read 8 tweets

Mourad H Senussi, MD, MS

@msenussiMD

Sep 22, 2020

(1/)I've had several people ask me about details on how to use bedside ultrasound to confirm ET tube placement, detect esophageal and mainstem intubations, and adjust positioning.

So here is a step by step guide!

Ref: journals.lww.com/ccejournal/Ful…

(2/)**Overview** this protocol utilizes sequential tracheal and bilateral thoracic lung ultrasound.
1. Tracheal ultrasound to r/o esophageal intubations
2. Right Lung US
3. Left Lung US
4. Adjustment to achieve bilateral lung sliding

(3/)**Tracheal Ultrasound**
This is simple. Place your transducer transversely at the level of the suprasternal notch. Below is an example of the appearance of the trachea with a hyperechoic anterior wall and acoustic shadowing.

Read 17 tweets

Mourad H Senussi, MD, MS

@msenussiMD

Jul 7, 2020

https://twitter.com/msenussiMD/status/1278480975643709440

(1/24)*De-mystifying Hepatic waveforms*
Welcome to Part 2. Now that we have gone through the basics:(

https://twitter.com/msenussiMD/status/1278480975643709440

). Time for a deep dive where we can start to decipher the important clinical information we need to apply at the bedside #showmethewaveforms #shocksquad

(2/24)We must acquaint ourselves with the different guises that HV waveforms may appear, they can be
- biphasic and tetrainflectional
- tetraphasic and tetrainflectional
- Increased antegrade flow (S and D magnitude)
- Increased retrograde flow (A-reversal, SR, DR)
See⬇️

(3/24)The fun doesn't stop there! We all know how the atrium augments flow to the ventricle. With atrial relaxation (analogous to x-descent on JVP) that downward deflection helps increase forward flow during systole. With TV closure, you can see a notched S-wave (S1, S2).

Read 26 tweets

Mourad H Senussi, MD, MS

@msenussiMD

Jul 2, 2020

(1/ )There has been an overwhelming interest in the use of hepatic waveforms as a congestive parameter. With social media, somewhat obscure concepts like these are quickly brought to the forefront and implemented in clinical practice. Many are eager to incorporate #VEXUS but...

...a thorough understanding of these waveforms, hemodynamic correlates, and dynamic changes that occur in physiology and disease, is paramount to incorporating this into practice. #shocksquad #tweetorial #VEXUS #showmethewaveform. Here are rules of interpreting hepatic waveforms

(2/13)Rule 1: **Nomenclature, nomenclature, nomenclature! **
That’s right! For us to understand each other we must speak the same language. I have heard these waves being described in a multitude of ways which has brought about considerable confusion and miscommunication.