Eduardo R Argaiz Profile picture
Jul 10, 2022 11 tweets 7 min read Read on X
#AKIConsultSeries Middle-aged male ➡️🏥 for painful knee and fever. Now in shock 🚨

📂Chart review: PMH EtOH Cirrhosis, right knee arthroplasty.

It is always a good practice review previous PACS images🩻: Nodular liver, colateral vessels and prosthetic right knee

1/11
On exam: BP 72/48, HR 82, O2Sat 95%.
CRT 7 sec, 🧠somnolent, confused. No edema, no obvious ascites.

Warm, swollen and erythematous knee: Tap with obvious purulent fluid🧫

Cr 2.8 mg/dl (baseline 0.5), K 6.7, Urine 🔬: hyaline casts, some urothelial cells

2/11
Loos like hemodynamic AKI (AKA Pre-renal)

Usual causes in Cirrhosis:

🔷Distributive: Septic, "Hepatorenal physiology" 🔷Hypovolemic: Laxatives, vomiting, large volume paracentesis
🔷Congestive: Porto-pulmonary HTN, Co-existing cardiomyopathy

3/11
What is the usual initial guideline-recommended treatment in this scenarios?

Cirrhosis + AKI: Albumin, fluids
Sepsis: Antibiotics, source control (prosthesis removal), fluids

¿Can we do better?

Yes, quick screen for fluid tolerance in 1 minute #POCUS: #IVC and #LUS

4/11
Lung Ultrasound (#LUS) looks ok, but IVC is plethoric 🚩🚩🚩

I have wrote about thus scenario before: criticalcarenow.com/albumin-for-vo…

Venous congestion needs further evaluation!

5/11
#Echofirst PLAx, PSAx, A4ch (RV view).

Good LV, Septal Shift (D-Sign), Dilated RV and RA, RV systolic disfunction and Severe Tricuspid regurgitation!

6/11
#Hemodynamics

#VExUS HV: S wave reversal, PV: Non pulsatile (Not reliable in Cirrhosis), IRVD: Monophasic.

RVOT Doppler: Notched Envelope

TRVMax: 2.8 m/sec (note triangular shape, because of severe TR, this can't be used to estimate sPAP)

LVOT VTI: 18 (not so bad)

7/11
This hemodynamic evaluation is compatible with pre-capillary pulmonary hypertension with severe venous congestion (monophasic IRVD)!

As previous echo (2 yrs ago) showed no evidence of PH, we got AngioCT: It ruled out PE

8/11
Working Dx: Septic arthritis with underlying Porto-pulmonary hypertension

#HemodynamicAKI: distributive + congestive

Fluids and albumin were 🛑

Vasopressin, NE, Levosimendan and Furosemide were started. Source was controlled

Despite MAP >80. Patient remained Oliguric

9/11
CRRT was initiated and a negative fluid balance of 3-4 L daily was obtained. After 48 hrs, pt started producing urine. We kept decongesting with diuretics.

Patient was fully decongested, AKI resolved.

Repeat #echofirst showed persistent severe PH and severe TR

10/11
Lessons:

1) AKI-Fluid reflex prevented by #POCUS (#IVC + #LUS to check for Fluid Tolerance)
2) In Cirrhosis, use intra-renal doppler for #VExUS (PV not reliable)
3) #VExUS can be used to monitor decongestion even in severe TR

POCUS Always

/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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