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A very interesting RCT by @MirjanaCihoric & @BangFoss in @BJSurgery show the importance of dexamethasone (DXM) in acute abdominal surgery! DXM ⬇️inflammation,⬇️vasodilation,⬇️pressor dependency, and improves fluid balance and even 90-day ☠️
doi.org/10.1093/bjs/zn…


2/
DXM shows positive effects on various secondary endpoints with different levels of significance. Also, less fatigue, pain, immobilization and better peak exp flow.

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🧵Can the pulmonary artery catheter (PAC) guide massive transfusion?
Key ideas:
1⃣Continuous SvO2 may be useful for optimizing O2-delivery.
2⃣Continuous SvO2 & CO aids in detecting distributive shock physiology.
#FOAMed #MedTwitter #CritCare #ICU 2/ 1⃣Optimizing DO2
The goal of transfusion is to improve O2-delivery. SvO2 is an excellent measure O2-delivery. PAC allows continuous SvO2 monitoring.

1/🧵The history of #EchoFirst for hemodynamic monitoring in #ICU to put this new study on continuous #AutoMAPSE in perspective!

🫀📜

@ICMexperimental #POCUS #TEE #MAPSE #MedTwitter #CardioTwitter #FOAMed #CriticalCare rdcu.be/dKPgA
2/
1⃣st report of TEE was in 1980, using M-mode from TGSAX during cardiac surgery. The rationale for this was: "Currently used monitoring techniques such as measurements of pressure and cardiac output provide an incomplete picture of LV function..."
doi.org/10.1016/0002-9…

1/ 🎯Bland-Altman analysis is the common way to evaluate AI in #EchoFirst. However, BA analyses can be tricky to interpret. 🧵On the paradox of BA analysis for AI in #EchoFirst with examples from our studies on #AutoMAPSE 📜
#Foamed #Cardiotwitter rdcu.be/dH8aR
2/ BA analysis is an important approach used for comparing 2⃣measuement methods for measuring the same unit, like #MAPSE (mm) and #AutoMAPSE (mm). ‼️Correlation (r) is inappropriate yet commonly used because it is seductive. Read the reasoning in their📜: doi.org/10.1016/S0140-…

🧵1/ #AutoMAPSE had high feasibility for estimating MAPSE from ≥1⃣wall. Many worry that #MAPSE is limited by RWMA, such as acute MI - however, evidence suggests that regional MAPSE reflects global LV function.

#EchoFirst #POCUS #FOAMed #CardioTwitter rdcu.be/dHLxx
2/ Several studies have shown that in AMI, MAPSE is ⬇️even in walls remote to MI. This was confirmed experimentally by Berg et al, in an experiment occluding the LAD in pigs and measuring #MAPSE by #WhyCMR.
First paper:
Berg et al: doi.org/10.1080/140174…
doi.org/10.1152/japplp…

🧵We have now refined AutoMAPSE.!
🔓
⬆️New paper on #autoMAPSE showing that the newest version achieves an optimal balance between feasibility, analysis speed, and agreement.
A🧵on the clinical importance of these findings
#echofirst #CardioTwitter #POCUS doi.org/10.1016/j.ultr…

https://twitter.com/AndersTasken/status/1772268429241667845

1/ Our design involved measurements from 🔟beats per #EchoFirst recording. This is very different from the usual practice of measuring 1-3 beats. What are the advantages?

The RVOT or PA Doppler has a lot of underutilized potential for hemodynamic monitoring of the RV #ThePeoplesVentricle

🧵On the physiology of the RVOT/PA Doppler. Simplified understandings. Corrections are welcome!😃
#FOAMcc #EchoFirst #Cardiotwitter #FOAMed #Medtwitter #POCUS VTI reflects stroke volume, but values are much lower than for LVOT. Lower cut-off for 60-79 year olds is actually around 10 cm.
Monitoring changes are likely more useful. doi.org/10.1016/j.jcmg…

🚨Automatic measurement of LV function in #ICU is possible by automatic measurement of #MAPSE using TEE and AI #AutoMAPSE
🔓

1/🧵Still, many prefer EF for LV function. How does MAPSE compare to EF, and is MAPSE better?
#EchoFirst #POCUS #FOAMed rdcu.be/dxsEU
2/ #MAPSE and EF are highly correlated. EF reflects SV/EDV, while MAPSE reflect SV/outer cross-sectional area.

Appreciate their relationship in this figure⬇️ doi.org/10.1152/ajphea…

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Many try to monitor LV function using #POCUS or #EchoFirst, but echo does not work for monitoring.

Let's understand why #POCUS fails at monitoring LV function and how #AutoMAPSE can help.
#MAPSE

🔓

@JcmcSoMe #FOAMcc #FOAMed #CardioTwitter rdcu.be/dw7fT
2/
The goal of monitoring is
1⃣to detecting small and early changes
2⃣so that therapies can help patients.

For successful monitoring, the measurements must be precise and acquired rapidly and effortlessly. Neither #EchoFirst nor #POCUS fulfil these criteria.

1/
Ventriculoarterial coupling (#VAC) determines the harms and benefits of hemodynamic therapies.

VAC describes cardiac efficiency, and offers a complementary perspective to CO, MAP and tissue perfusion.

Let’s try to understand it🧵
#FOAMcc #FOAMed #MedTwitter #CardioTwitter 2/
VAC is the matching afterload (Ea) to contractility (Ees) and reflect the heart's energy efficiency.

VAC can be understood using the analogy of riding a bicycle.

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#MAPSE: an unappreciated treasure for assessing LV function? #EchoFirst #WhyCMR

#MAPSE is easy and feasible in almost every patient, also in #ICU. It is highly prognostic, yet unpopular. The reasons are not rational.
🧵👇

#CardioTwitter #POCUS #FOAMed #MedTwitter 2/
#MAPSE is easy to measure using #EchoFirst, and was described already in 1967:

However....doi.org/10.1093/cvr/1.…

1/🧵Suppl. material for abstract @ESICM #LIVES2023
LV dysfunction in #ICU is bad, yet the LV is not monitored.

Can we use #TEE➕AI➕#MAPSE to monitor LV function in ICU? ✅Yes, #AutoMAPSE had excellent feasibility!

#FOAMcc #FOAMed #MedTwitter #CardioTwitter #EchoFirst #POCUS 2/  INTRODUCTION

As LV function is a crucial for effective hemodynamic management, one would expect it to be closely monitored in #ICU patients - but its not.

LV function is only assessed intermittently, and often assessed late and when LV dysfunction is severe and complicated.

1/🧵
Hypovolemia➡️hyperdynamic LV. Maybe not!

Take home:
Hypovolemia➡️reduced LV function; Hyperdynamic LV is mainly due to low afterload, not hypovolemia.
#POCUS #EchoFirst #FOAMed #FOAMcc #POCUS 2/
In this recent study (EJA 2023), authors show that hypovolemia, with ⬇️SV and ⬇️CO, but without hypotension, is associated with ⬇️LV &⬇️RV function. Is this coherent with real-life?
doi.org/10.1097/EJA.00…

MAPSE in #IntensiveCare (with examples)🧵#FOAMcc #FOAMed #MedTwitter #Hemodynamic #POCUS #EchoFirst #CriticalCare
Take homes:
1⃣ Redefining "the hyperdynamic heart" with #MAPSE
2⃣ MAPSE is better than EF in the #ICU
3⃣ Linking MAPSE with supply/demand-ischemia
1/n 1⃣ Can MAPSE redefine "the hyperdynamic heart?
The term "hyperdynamic LV" - EF > 55% - is misleading. It has no relation to a hyperdyanmic circulation; SV/CO. Someone bleeding to death has a hyperdynamic heart, but the circulation is life-threatening hypodynamic.
2/n

A case of low ScvO2 (60%), high PvaCO2 (8.2 mmHg), fluid intolerance (CVP 11) and fluid responsiveness (PPV 17). What's the physiology and what to do?
#FOAMcc #Hemodynamics #ThePeoplesVentricle #FOAMed #Fluidtolerance #Cardiotwitter #CriticalCare Post-cardiac surgery. MAP 70, HR 95, low dose pressor. High CVP (11 mmHg) with pathologic waveform of x < y-descent. PPV > 17 despite low Vt (< 6 mL/kg). Normal blood gasses, normal lactate.