Thread by @ArgaizR

Young pt ➡️ 🏥 worsening shortness of breath

PMH: ESRD. Only 1 HD session/week. However, residual urine volume has now decreased substantially

On exam: BP 134/94, 2L O2,🧠✅, elevated JVP, decreased 🫁 sounds at bases, No murmurs, very mild edema. Functional left BC AVF

1/13

Careful examination of neck veins reveals no pulsations, even with pt sitting up 🤔

What could explain the absence of venous pulse? 2/13

Answer is all of the above. JVP examination can be complicated in pts with ESRD.

In the absence of pulsations, I find #POCUS much helpful. Let's enhance our physical examination of congestion:

3/13

#POCUS

#VExUS: Plethoric IVC, Hepatic Vein with significant flow reversal and Portal Vein with 100% pulsatility. (Intra-renal Doppler not done because of ESRD)

Also, PLAPS shows "spine sign" = Pleural Effusion

This is severe venous congestion!

(#VExUS refresher👇)

4/13

Laboratory Data📊: BUN 104 mg/dl, K 6.2 meq/L, HCO3 16 meq/L, T Bili 0.5 mg/dl, ALT 1166 U/L, AST 697 U/L

What is the next step in management?

5/13

🚨🚨🚨 This patient NEEDS further evaluation!

Venous congestion ≠ Hypervolemia

Venous congestion needs a differential diagnosis!!

DDx of severe congestion:

Left Heart Failure
PAH
High Output Heart Failure (AV Fistula)
Obstructive physiology

#Echofirst is a MUST

6/13

⬆️⬆️⬆️ LFTs suggest ischemic hepatitis.

Low cardiac output has to be ruled out!

A quick look at the heart from a subxifoid window reveals a large pericardial effusion with RA collapse

Is this tamponade?
Pt has normal BP, CRT is 3 seconds, lactate is 2.9

7/13

💡This degree of venous congestion is usually seen in severe PAH: I would expect RV failure and a very dilated RA

The combination of SEVERE venous congestion + Collapsed RA is highly suggestive of Tamponade Physiology

Advanced #POCUS skills are needed here!

#PLAx 👇

8/13

PLAx shows intermittent RV collapse,

It is sometimes hard to tell it this is happening in diastole (a sign of tamponade). So M-Mode through the Mitral Valve can help.

Here it shows clear diastolic collapse!

9/13

Another sign of tamponade is the equivalent of "pulsus paradoxus":

During inspiration, ⬆️ ventricular interdependence cases ⬇️ flow. So changes in flow with respiration are expected in tamponade

Trans-Mitral, Trans-Tricuspid and LVOT VTI: Significant variation!

10/13

Tamponade Physiology is present!

Even with normal BP, the liver is suffering from significant ischemia (ALT 1166 U/L).

One could have been tempted to start ultrafiltration to decongest the liver. This has a high likelihood of precipitating cardiac arrest! 🚨

11/13

Ultrafiltration was canceled and instead pericardiocentesis was performed!

After this procedure, no more signs of increased ventricular interdependence were present 👇

12/13

Venous congestion resolved (#VExUS = 0) and LFTs normalized!

🔑Venous Congestion ≠ Hypervoemia
🔑Venous Congestion needs a DDx
🔑Tamponade causes congestion and increased ventricular interdependence
🔑Decreasing intravascular volume in pts with tamponade should be avoided

/End