Eduardo R Argaiz Profile picture
Mar 17, 2022 10 tweets 4 min read Read on X
#AKIConsultSeries 👵➡️🏥 w necrotizing fasciitis s/p debridement. Significant 🩸 during surgery ➡️ intensive resuscitation (transfusions + crystalloid)

48 hrs later 💧📈 =+13 L, Edema +++, Hypoxemia, pleural effusion.

Now anuric unresponsive to high dose IV diuretics 1/10 Image
Cr 3.2, K 3.5, HCO3 25, Hb 8.9, WBC 26k, 95% PMN, Lactate 2.5

MAP 65 on NE (0.02 ucg/kg/min), HR 130, O2 sat 80-85 on 15 L NRB, RR 17 but w increased respiratory effort.🧠 drowsy, CRT >8 sec👇, JVP not elevated

Primary team consults for RRT initiation with ultrafiltration 2/10
What would you do next? 3/10
#POCUS Very difficult acoustic window*

Collapsed IVC, Hyper-dynamic LV🫀 (++++), Pleural Effusion and 3-5 B Lines per zone bilaterally (not shown)

4/10
🚨🚨🚨 Warning 🚨🚨🚨

Dynamic Left Ventricular Outflow Tract Obstruction (DLVOTO) could be happening here!

💡Think of this when you see: Severe sepsis, ⬆️tachycardia, ⬇️ preload, kissing LV walls, mottled skin and ⬇️ pulse pressure

Be prepared!

journals.sagepub.com/doi/10.1177/03…

5/10
🚨DLVOTO can occur with significantly decreased LV filling volume

The inter-ventricular septum or the mitral valve might obstruct the LV outflow tract and cause a significant reduction in stroke volume

6/10 Image
Remember obstruction causes an increase in velocity, so Doppler is essential for diagnosis

Even with a poor acoustic window, a simple CW Doppler through the LV Outflow Tract revealed a velocity of 4.3 m/s (gradient = 73 mmHg)!

This confirms DLVOTO!

7/10 ImageImage
Treatment needs to be fast ⚡️

Maneuvers to increase LV volume: 1) Fluid Bolus, 2) Stop Inotropic Drugs, 3) Use non-inotropic vasopressor, 4) Carefully consider Beta-blocker

After fluid bolus and 🛑 NE, LVOT velocity decreased to less than 2!

8/10 Image
⚠️Fluid is not going to be a permanent fix because of expected extravasation!

A vasopressor with no inotropic/chronotropic properties should be initiated!

Vasopressin was given (0.08 UI)

Vitals improved, LVOT velocity remained < 2 m/s and UOP rose to >100 ml/hr!

9/10 Image
DLVOTO is a catastrophic but potentially reversible condition. Be prepared!

If you want to learn more about DLVOTO here is another case of mine with a detailed explanation of the physiology of obstruction:



END/

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More from @ArgaizR

Sep 17, 2023
👩♀️ Past Medical History: SLE, Antiphospholipid syndrome, portal vein trombosis, ESKD on HD, 🫀Group 1 PH + Severe TR

Now with worsening ascites (Para: SAAG > 1.1, total protein 2.5 g/dL). Lowering dry weigh was attempted..

BP 90/60. No edema. On room air, ⬆️ JVP

#POCUS

1/8
Is this cardiac ascites? Should we lower dry weight even further?

2/8
🔷 Although IVC is plethoric, this is not reliable in severe TR

🔷 VExUS can't be performed here (Portal Vein Trombosis, ESRD very small kidneys)

How about HV Doppler and Femoral Vein Doppler? 👇

Is this severe congestion? I do not think so! They also reflect severe TR!

3/8
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Read 8 tweets
Aug 4, 2023
Hemodynamic Evaluation of Right-Sided Congestion With Doppler Ultrasonography in Pulmonary Hypertension @AmJCardio



50 days' free access link: https://t.co/ADD3F7NgEf

🧵of our findings 👇 (1/6) https://t.co/ORDsb9Nu4rdoi.org/10.1016/j.amjc…
authors.elsevier.com/a/1hXCqgQkyqNA

Image
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1⃣ Intra-Renal Doppler (IRVD) alterations are usually classified using morphological patterns (Continuous, Biphasic, Monophasic)

Looking at the relationship between Portal Vein Flow and IRVD you can notice the "Biphasic" pattern shows a very large spread of values! (2/6)
Image
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Switching to a classification based on interruption-time identified pts with a "Biphasic" pattern who were non-congested (short interruptions) or severely congested (long interruptions)

This classification has a much better agreement with Portal Vein Alterations! (3/6)


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Read 6 tweets
Jul 7, 2023
👴 w Cirrhosis ➡️🏥 with spontaneous bacterial peritonitis and septic shock

After fluid resuscitation, vasopressors and antibiotics shock resolved

However now with oliguria and ⬆️ Na (165 meq/L). Cr 1.0 mg/dl, BUN 30 mg/dl

1/10
BP is 155/63 (MAP 94), HR 77, O2 is 94 on O2 8 L/min.

🧠 Encephalopahy on tx w lactulose, edema +++, CRT 1 second, mild ascites.

#POCUS LV/RV OK, LVOT VTI 40 (CO 9.8 L/min), B-Lines, VExUS = 2 (Plethoric IVC + Biphasic Intra-renal Doppler) ➡️ High Output Heart Failure

2/10
1⃣¿Why is the pt Oliguric?

Is this hemodynamic AKI?

🔷Hypovolemic unlikely given congestion and ⬆️ CO

🔷Distributive? Although pt has Cirrhosis, MABP is 94 without vasopressors, also unlikely

🔷Congestive? Possible given VExUS 2

3/10
Read 11 tweets
Feb 27, 2023
HV Doppler from a pt with severe group 1 pulmonary hypertension 👇

Many of us don't have ECG when doing POCUS...

Is it posible to determine this waveform components?

The answer is yes! I'll show you how I did it here

A 🧵on HV Doppler in Pulmonary Hypertension

#VExUS 1/12 Image
Normal HV is a mirror image of normal CVP waveform.

It usually has 4 waves:

2 antegrade (flow from liver to 🫀) waves (S and D)

2 retrograde (flow from 🫀 to liver) waves (A and V)

2/12 ImageImage
A frequent alteration in pts w severe PH is Severe Tricuspid Regurgitation

In severe TR, there is retrograde flow from the RV to the RA in systole. If the right atrium is not compliant, this flow reaches the HV and gives a reverse S wave!

Example from another case 👇

3/12 Image
Read 12 tweets
Jan 29, 2023
Young ♀️ w CKD on HD, seen in Cardiorenal clinic

Pt had torrential tricuspid regurgitation due to CVC induced leaflet perforation ➡️ She underwent tricuspid valve replacement surgery 🫀🔪

However, 1 month after discharge she is still using a wheelchair 🤔

1/12🧵
#POCUS above shows plethroic, non-collapsible IVC and Hepatic Veins

Did surgery work?

Is there residual tricuspid regurgitation?

#Echofist (PLAx RV view + A4ch) color Doppler lets us see there is no or minimal TR

Prosthetic valve seems to be working

2/12
But there is still venous congestion. In fact congestion is significant, take a look at portal vein Doppler 👇

Pulsatility Fraction = 40%, this means there is significant venous congestion. Why?

Is this just volume overload? Should we probe a lower dry weight?

3/12
Read 13 tweets
Dec 28, 2022
Ambulatory Hemodialysis Unit Rounds:

Called to see a patient with hypotension: BP 76/40,🧠 OK, CRT 5 seconds

1st step ➡️🛑Ultrafiltration + 300 ml bolus. BP 90/60

Pt is a middle aged ♂️ w ESRD and T2DM

1/9 🧵
Now 3 kg above Dry Weight.

UF Volume so far: Only 600 ml

🔎📁 Previos HD sessions with no hypotensive episodes

1 week with URI symptoms, 2 days with dyspnea on exertion

On exam: No leg edema, Clear 🫁, JVP hard to assess (hx of multiple CVCs and central vein stenosis)

2/9
#POCUS:

Pericardial Effusion, Normal LV function, looks like there is some RV colapse

Plethoric IVC, Portal Pulsatility 39%.

A-Pattern on LUS, Small bilateral pleural effusions

🚨⬇️BP + Collapsing RV + Venous Congestion (IVC + Portal Pulsatility) suggests Tamponade!

3/9
Read 9 tweets

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