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IMCrit Profile picture
@IM_Crit_
May 25 • 8 tweets • 4 min read Twitter logo Read on Twitter
ICU stories (last night): A patient had been admitted w pneumonia / intubated / on norepi 0.12. At 01:00 am, the nurse notifies you that urine output is 5-10 cc/hr for the previous 3 hours. BP is 99/44, HR 90, CRT 3 sec. You take the US in patient's room to see what's happening.
What POCUS finding(s) is/are likely to explain the oligo-anuria in the shortest amount of time?
If you (and the patient) are lucky, you may find this:
If you want to be fancy: ImageImage
A simple formula to estimate the urine volume provided by pocus101.com/bladder-volume… Image
It turns out that the patient had a male external condom catheter and urinary retention. Image
In just 30 min last night, POCUS explained an episode of oligoanuria 👆, ruled out a sinister undifferentiated shock etiology (it was "just" septic shock that reached norepi 0.35 before ICU arrival) and explained a resp failure (it was aortic insufficiency)
Thanks for reading!

#FOAMed #FOAMus #FOAMcc #MedTwitter #MedEd @NephroP @MynephCC #MedStudentTwitter

PS: The "consult to Nephrology" was cancelled...

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More from @IM_Crit_

IMCrit Profile picture
May 12
ICU stories: Pt w "severe COPD" (ex-smoker; FEV1 30%) / chronic hypoxic-hypercapnic resp failure on 2-4 l/m O2 @ home / diastolic HF / HTN / HLD was brought to the ED due to "altered mental status" & "shortness of breath". S/he left the hospital 3-4 months ago after an episode
of "COPD exacerbation" (the 4th during the last 12 months). In the ED: sat in low 80s & after a brief non-rebreather mask trial, pt was placed on NIV. ABGs: PCO2>100 (above detection limit), pH 7.14, HCO3 undetectable. Pt suffered 2 grand mal seizures, & after receiving
lorazepam & 2l NS, s/he was intubated (roc+keta) & rushed to the ICU. Per ED: ECG w sinus tach & CXR "COPD lungs" & R basilar infiltrate. Labs: WBC 14K, creat 2.0 (baseline 1.4). You examine the pt quickly: sedated-?paralyzed/decr BS & wheezing bil/trace ext edema/skin not cold
Read 23 tweets
IMCrit Profile picture
Apr 28
ICU stories (a brief one): A 40+ yo pt w hx of bipolar disorder/asthma/GERD/HTN was brought to the ED by EMS after his wife found him lethargic ("altered mental status"). Apparently, he had spent the previous 2 days isolated in his forest cabin. Upon ED arrival, he was obtunded
& was given Narcan with no improvement. Vitals: 140/90, hr 80, rr 22, afebrile, sat 97% on room air. He could respond to simple questions. CT brain was negative. Lab work/up showed Hct of 59%, wbc 11k, PLT 400k and a chemistry panel showed: Image
A urine drug screen was sent 👇 while patient admitted that he had probably taken more Xanax (alprazolam) pills than he should. However, he denied that he wanted to hurt himself. Image
Read 18 tweets
IMCrit Profile picture
Apr 27
ICU Reminders:

RV-predominant cardiogenic shock

RV failure criteria: Image
RV pressure-volume loops: Image
Etiologies of RV failure: Image
Read 6 tweets
IMCrit Profile picture
Apr 27
ICU "news":

Have you heard about the Doraya catheter? It is percutaneously deployed in the IVC below the level of the renal veins & works as a temporary iv flow regulator -> partially obstructing the venous flow -> ⬇️ cardiac preload & venous congestion Image
In a very small preliminary study, the catheter was placed in 9 patients (LVEF 24±12%) for a mean duration of 8.5 hours. The catheter deployment led to significant pressure ⬇️ above the device 12.4±4.7 mmHg, when compared to unchanged pressure below the catheter 18.5±6.2 mmHg
Diuresis was 77.1±25 ml/h at baseline, and 200.8±93 ml/h during device deployment with average peak urine output of 294 ± 139 ml/h... Spot urine Na increased from 35 to 101 mmol/l

Reference:
jacc.org/doi/10.1016/j.…
Read 6 tweets
IMCrit Profile picture
Apr 21
ICU Pharmacy pearls:
If u have not heard the news, there is a national shortage of IV hydrocortisone (HC) ...
ashp.org/drug-shortages…
So, if u are like me & use often HC in septic shock, u need to be aware of other options. If HC (Solu-Cortef®) is not available, consider use of
an alternative parenteral corticosteroid: methylprednisolone (MP) (Solu-Medrol®) or dexamethasone (D)

The "problem" w these two drugs is that they have minimal mineralocorticoid activity, so u may need to supplement them w fludrocortisone (FC)
This should not be a totally unknown practice for intensivists, since the "prototype" of positive steroid trials in septic shock, the Annane trial published 20 years ago in JAMA (jamanetwork.com/journals/jama/…) implemented a 7 day course w iv hydrocortisone AND enteral fludrocortisone
Read 7 tweets
IMCrit Profile picture
Mar 28
Since I (re-)started the albumin debate
I have to bring more info to the table:

"Anti-albumin":
"Pro-albumin":
Read 4 tweets

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