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Mar 5 16 tweets 7 min read
ICU stories (a brief one): 60 yo male w lung cancer / CAD / HTN / HLD / status post chemotherapy a month ago presented to the ED w SOB/cough/weakness after failing outpatient tx w azithromycin. CT chest: no PE but positive for bilateral consolidations:
Patient came to the ICU intubated, sedated, on pressors & antibiotics for PNA. Next step: POCUS. PLAX looked "weird", so Doppler and "zoomed" views were recorded:
PSAX & subcostal views:
4-chamber views:
IVC:
What was this 👆incidental finding (?) in the IVC?
This was an IVC filter. Returning to the POCUS (skipping the lung & VEXUS parts of it): it showed significant thickening of the tips of both the anterior and posterior MV leaflets. A TEE was performed two days later:
It confirmed thickening of the tips of both the anterior and posterior MV leaflets w mobile echodensities consistent w vegetations. There was a MR jet central to posteriorly directed w flow reversal in the pulmonary veins (not shown here).
What did the blood cultures grow?
Blood culures (and the rest of the ID workup) remained negative. Most likely scenario: patient had non-bacterial thrombotic endocarditis (also known as marantic or Libman-Sachs)
Take-home messages:
1. According to Hickam's dictum: "patients can have as many diseases as they damn well please". Interestingly, this aphorism was stated many years before POCUS became common practice! Sadly, I have not myself searched for the origin of this principle.
It is attributed to John Hickam, Chair of the Department of Medicine at the University of Indiana. According to the legend, Hickam was housestaff in the Department of Medicine at Grady Memorial Hospital in Atlanta. Knowing Grady Hospital quite well, I have little doubt that
the principle was borne there...
2. Nonbacterial thrombotic endocarditis (NBTE) is most frequently associated with neoplasia but also w SLE, RA, antiphospholipid syndrome, multiple myeloma, Crohn’s disease etc & of course, w COVID-19. Systemic embolization is
the most common clinical manifestation. NBTE vegetations are most frequently L-sided, w 2/3 involving the MV & the remainder the AoV. It cannot be distinguished from infectious endocarditis w imaging alone. Even w anticoagulation, its prognosis is unfavorable due to the
association with the primary condition, such as advanced cancer

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More from @IM_Crit_

Feb 25
ICU stories (from the trenches): 70 yo pt w hx of A-fib/CAD/ICM w EF 25%/VT ablation s/p BiV ICD/CKD/HTN/HLD/peripheral vasc dz/COPD etc presented to outside 🏥 w SOB/weakness/falls. Labs: wbc 15k/creat 3.5 (baseline 2.0)/INR: 8.5/AST/ALT/Tbil: 180/250/3.0, lactate 3.5
RUQ US was obtained to work-up elevated LFTs:
Diagnosed w bilateral PNA/AKI/liver dysfunction. Treated for sepsis w ivf boluses, broad-spectrum antibiotics, steroids, bicarb. Continue to get worse; due to ⬆️O2 needs, transferred to our 🏥. I saw her the next am: in resp distress while on BiPAP 15/10-100%, abg 7.26/50/70/19.
Read 30 tweets
Feb 24
Nice paper on cardiorenal syndrome (CJASN; 2023. doi: doi.org/10.2215/CJN.00…)

Proposed pathophysiological pathways leading to the cardiorenal syndrome and its complications
"The inciting event is usually an acute decompensation of heart failure. This may lead to either arterial underfilling or venous congestion as mediators that promote neurohormonal activity, inflammation, & endothelial dysfunction. In combination, these pathways lead to ⬇️ in GFR.
Complications include Na avidity and fluid retention, reduced kidney clearance, and endocrine function, all of which further perpetuate the pathophysiology".
Read 4 tweets
Feb 4
ICU stories (a common one): It's Saturday, Jan 28, 2023. You just came on service at 7:00 am & at the same time, they were rolling in a case from the OR (Friday night case = never good...). 65 yo pt w DM2/diastolic HF/CAD/A fib/HTN/PVD. Had 10 ds' hx of abd pain; CT A/P showed
evidence of ischemic bowel. Pt came to the ICU after an exp-laparotomy w partial small bowel resection. The gut was left in discontinuity & the abdomen was left open. Pt still sedated & paralyzed, on norepi 0.18. A sleep-deprived anesth CRNA is telling you that the surgeon plans
to bring the pt back to OR for 2nd look on Monday. You feel so lucky; pt already has lines from the OR, you just have to keep him sedated for 2 days. Piece of cake! You move on to the other pts but the RN interrupts your dream rounds in 5 min. What about maintenance fluids, doc?
Read 19 tweets
Jan 29
ICU stories (a brief one): One hour before the end of the am shift, u walk around in the ICU to make sure thinks look OK before u type your sign-out note. You spot the resp therapist & the nurse bagging the pt in Rm 306. From the hallway, u see the monitor: HR 160, RR/45, Sat 70%
This is a 30 yo pt w hx of a catastrophic brain bleed, s/p trach & PEG, admitted 2 wks ago w MDR Klebsiella UTI. Doing well, on trach mask 28%, until the episode of acute/unexpected desaturation
When u examine the pt, s/he is in extremis (accessory muscle use-tachycardic-tachypneic-diaphoretic). BP: 105/55. You grab the stethoscope that the resp therapist wears around his neck & you hear breath sounds in both sides (pt is skinny...)
Read 24 tweets
Jan 15
Judging from yesterday's post, many friends are interested in how to get the most out of these books 👇 and ace the exams, so a few more tips are on their way:
1. Tylenol use can lead to high anion gap metabolic acidosis. Don’t ask me about the mechanism!
2. Every patient who manages to fly eastbound with Southwest Airlines & subsequently develops pneumonia not responding to common antibiotics has actually blastomycosis
3. Every oncology patient who receives chemo is destined to develop tumor lysis syndrome. Please learn about hydration/allopurinol/rasburicase
4. Along these lines, every oncology patient on immunotherapy will develop pneumonitis. Remember the steroids from yesterday’s post?
Read 8 tweets
Jan 15
These books from @accpchest & @SCCM represent my study goal for this month. Before starting any (re-)certification exam & especially f you want to ace the tests, there are a few recent trends (& old habits/tricks) that you need to be aware of:
1. If there is an option of "doing nothing", this is most likely the correct answer.
2. There is always a mixed metabolic disorder. Memorize Winter's formula.
3. Prepare for several COVID-19-related questions. No surprise here...
4. TEG is very popular. Even of you are a dinosaur, you have to learn the basics about visco-elastic tests.
5. I know you have no CAR T-cell therapies in your hospital (& no one can really spell them correctly), but be prepared for managing cytokine release syndrome.
Read 9 tweets

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