Thread by @OBsleepmerchant

Dr Clemens Ortner, MD continues the #Solshnider track, speaking on #POCUS in the #OBAnes emergency - How can we guide care? #SOAPAM2023

Case 1. Why was focused TTE not being used more widely in #OBAnes? #SOAPAM2023

Learning objectives. #POCUS #OBAnes #SOAPAM2023

Questions answered by FOCUS. Multiple differential diagnoses with different and often opposing management. Getting it right, saves lives. #POCUS #OBAnes #SOAPAM2023

FOCUS is a rapid point of care modality delivering a targeted diagnostic test, with multiple diagnostic targets. #POCUS #OBAnes #SOAPAM2023

How is it done? Dr Ortner advises expanding cardiac FOCUS to include lung and upper abdominal views. Is it feasible in pregnancy? Anatomical changes in pregnancy ideal for parasternal and apical views. However, there are challenges (not necessarily pregnancy related) #POCUS… twitter.com/i/web/status/1…

Certain images may be more difficult to obtain under certain circumstances. What is the yellow ???? A breast implant - decreasing image acquisition to <50%. So the challenges list expands. #POCUS #OBAnes #SOAPAM2023

Case 2. G3P2 Hx asthma, SOB. Treated as asthmatic attack. The algorithmic benefits of pulmonary ultrasound, with diagnostic accuracy. #POCUS #OBAnes #SOAPAM2023

Experimental evidence. # of B lines increase with progressing ALI BEFORE Pa/Fi ratio decreases, and correlate with wet dry ratio. There is a learning curve. What’s normal in pregnancy? #POCUS #OBAnes #SOAPAM2023

Back to Case 2. First step: B lines or A lines. Findings. > 3 B lines in > 2 quadrants = interstitial pulmonary syndrome -> increased EVLW. #POCUS #OBAnes #SOAPAM2023

So having seen B lines bilaterally, what is the LVEDP? Case 2 = Preeclampsia with preserved systolic function. #POCUS and preeclampsia: preserved systolic function +/- diastolic dysfunction. #OBAnes #SOAPAM2023

Increased LVEDP = cardiogenic oedema. Diagnosis Case 2 = Preeclamsia in acute pulmonary oedema. #POCUS #OBAnes #SOAPAM2023

Pulmonary ultrasound #POCUS and preeclampsia. 25% interstitial pulmonary syndrome present in preeclampsia with systolic failure. 19-20% raised LVEDP - associated with B pattern. A pattern excludes raised LVEDP. #OBAnes #SOAPAM2023

Case 3. Emergency cesarean for non-reassuring FHR, luckily epidural in place.

EXCEPT it has no block. GA induced, uncomplicated ETT. BP a tad low. NO response to 500mcg phenylephrine.
#POCUS #OBAnes #SOAPAM2023

#POCUS reveals decreased systolic function. Early vs late disease. #OBAnes #SOAPAM2023

Assessing fluid responsiveness. IVC assessment is not sensitive in spontaneous respiration. Dr Ortner does not use it. PLR testing is his preferred technique. Better sensitivity and specificity compared to IVC. #POCUS #OBAnes #SOAPAM2023

Dr Ortner has evidence to support PLR vs IVC in preeclamptic patients with oligouria. #POCUS #OBAnes #SOAPAM2023

Case 4. PACU patient. Hypotensive and tachycardic. Block receding. Brief improvement with fluid bolus. #POCUS views suggest hypovolemia. #OBAnes #SOAPAM2023

FAST scan of RUQ. Fluid in Morrison’s pouch. Some intraperitoneal fluid post cesarean is normal. However, even a trace fluid in Morrison’s pouch correlates with large amount, the volume dependent on scan position. Hypovolemia + positive FAST = early OR take back. #POCUS #OBAnes… twitter.com/i/web/status/1…

Hypovolemia and the “kissing heart”. Kissing papillary muscles = end-systolic LV cavity obliterated. NOT only hypovolemia though - also distributive shock. Differentiate on LV-EDA. <10cm2 = hypovolemia, >20cm2 = distributive. #POCUS #OBAnes #SOAPAM2023

Summary slide from Dr Clemens Ortner: #POCUS has multiple utilities in #OBAnes. Join @SOAPHQ POCUS SIG. #SOAPAM2023

@threadreaderapp unroll please