Share this page!

Eduardo R Argaiz Profile picture
Twitter logo
28 Nov, 5 tweets, 4 min read
Pt with advanced Cirrhosis

AKI, Oliguria + Encephalopathy

Initial treatment = Albumin + Lactulose enemas

🧂Na is now 158 (From Lactulose induced free water loss)

#POCUS ninja @tumleal noticed something was wrong! He got his probe and texted me

📱 #WhatsAppAKIConsult 1/5
#POCUS: Plethoric non collapsible IVC

Based on the clinical scenario, IVC, heart rate and Pulse Pressure...

What is the likely underlying pathophysiology? 2/5
@tumleal went ahead and confirmed his suspicion:

He 📲texted me this:

LVOT VTI = 38!

Some 🔢:

VTI of 38, assuming a LVOT diameter of 20 mm: Stroke Volume = 119 ml

119 ml x HR (93 bpm) = 11.1 L/min of CO!

This is High Output Heart Failure (Very common in Cirrhosis) 3/5
⬆️ pulse pressure suggested ⬆️ Stroke Volume. This + Tachycardia meant High Cardiac Output!

This was confirmed by #POCUS (great job @tumleal)

The cause of High Output Heart Failure (HOHF) is low peripheral vascular resistance

More on HOHF here:
4/5
Treating the underlying cause (vasodilation) with vasopressors would likely increase renal perfusion, urine output and help the kidney get rid of extra sodium (hypervolemic hypernatremia)

This actually happened! UOP, AKI and hypernatremia resolved with pressors!

/END

• • •

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!

PDF

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

Eduardo R Argaiz Profile picture
21 Oct
Pt w right HF and high probability pulmonary hypertension

TAPSE 15 mm, TRVmax 4.1 m/s, paradoxical septal motion

Renal Venous Doppler 👇

According to doi.org/10.1161/JAHA.1…, Which curve color would best describe this patient's PH-related morbidity?

Poll and 🧵👇

1/6 ImageImage
Which curve in the Kaplan Meier Curve above best fits this particular patient?

2/6
The Renal Doppler shown 👆 looks like a biphasic pattern. This would mean the green curve 🟢

However there is a catch.....

3/6 Image
Read 6 tweets
Eduardo R Argaiz Profile picture
28 Aug
One of my favorite and most intriguing causes of severe venous congestion (#VExUS = 3)

A 🧵on High Output Heart Failure (HOHF) 1/18
First, the index case:

Clip above shows hyperdynamic flow from the vena cava

#echofirst 👇: Very dilated and plethoric IVC, LV OK, Dilated RV, D sign

Overall: Increased Right heart filling pressures

2/18
IVC = 3.4 cm
Portal Vein = > 100% pulsatility
LVOT VTI = 26
TRVmax = 3.04 m/s

So we have:

Venous Congestion (IVC, Portal Vein)
High Cardiac Output (LVOT-VTI)
Pulmonary Hypertension (TRVmax)

3/18
Read 18 tweets
Eduardo R Argaiz Profile picture
13 Jul
#AKIConsultSeries

👴 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

1/7
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?

2/7
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!

3/7
Read 7 tweets
Eduardo R Argaiz Profile picture
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

2/12
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
Eduardo R Argaiz Profile picture
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
Eduardo R Argaiz Profile picture
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

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

Thank you for your support!

Follow Us on Twitter!

Like this author's thread?

Get emails when @ArgaizR has new unrolls!

Check out other threads from @ArgaizR!

Read all threads by @ArgaizR

:(