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

Eduardo R Argaiz

@ArgaizR

Dec 28, 2022 • 9 tweets • 5 min read • Read on X

Scrolly

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

Hepatic Vein Doppler shows characteristic D wave reversal!

Again: This is strongly suggestive of Tamponade!!🚨

4/9

Also..LV looks very empty. LV walls can get too close together and obstruct the flow of blood!

Obstruction causes blood to speed up! (think of thumb on a hose).

Velocity is 3.5 m/s (very fast) with a gradient of 50 mmHg! This is Hemodynamically significant obstruction!

5/9

In order to improve obstruction, we need to increase preload of the LV! Pericardiocentesis will achieve this (by relieving RV collapse)

In the meantime, a fluid bolus can be a temporizing measure.

More on the physiology of LV obstruction here:

https://twitter.com/ArgaizR/status/1580777299531558912?s=20&t=tN8gm3kveKRwK1gq6BXvEg

6/9

Gave an extra 300 ml fluid and arranged ICU admission!

Fluid did help: BP now 105/69, gradient improved from 50 to 24 mmHg!

However, liver congestion got worse: Portal Vein Pulsatility now 62%. This is not good, especially since LFTs came back ⬆️⬆️⬆️

7/9

Pericardiocentesis was performed, this fixed everything!

BP now 153/76.

Portal Vein is no longer pulsatile

Hepatic vein shows no D wave reversal

Gradient is now 4.8 mmHg (Not hemodynamically significant!)

8/9

Learning Points:

🔷#POCUS can help in the evaluation of intradialytic hypotension
🔷Venous congestion ≠ Volume Overload
🔷Tamponade ➡️ Low LV preload ➡️ Obstruction (if predisposing conditions)
🔷Fluids worsen congestion, but can be an adequate temporizing measure

/END

• • •

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 @ArgaizR

Eduardo R Argaiz

@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

Read 8 tweets

Eduardo R Argaiz

@ArgaizR

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

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)

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)

Read 6 tweets

Eduardo R Argaiz

@ArgaizR

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

Eduardo R Argaiz

@ArgaizR

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

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

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

Read 12 tweets

Eduardo R Argaiz

@ArgaizR

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

Eduardo R Argaiz

@ArgaizR

Nov 22, 2022

#AKIConsultSeries:👨w T2DM➡️🏥 for fever, dysuria and CVA tenderness. On arrival: ⬇️BP, ⬆️Glucose, ⬆️AGMA. Dx UTI + DKA. Tx: Abx + Insulin Pump + 4 L Crystalloid + NE

After resus, pt still oliguric, Cr 3.2. NE 0.7 ug/kg/min,🧠confused, BP 85/62, HR 123, 2L O2. CRT 4 sec

1/12

Given DKA, giving additional fluids is tempting. But before we do this, its easy to do a quick assessment of fluid tolerance #POCUS

#LUS shows some B-lines (bilat)
#IVC plethoric w no respiratory collapse
#VExUS shows very pulsatile portal vein 🚨🤔

2/12

Pulse pressure is low (23!): This suggest a low cardiac output state!

Also, there are signs of fluid intolerance!

#EchoFirst: Window is suboptimal, but we see a Hyper-dynamic LV w small cavity and a turbulent flow (green color). There was no systolic RV failure

3/12