For @NephroP, estimation of intra-abd pressure during para.

Once para catheter is in, can connect the tubing for the vacuum bottles to the stopcock and use this as a manometer. (Akin to opening P on LP).

This is not marked, so I mark with skin marker every 5 cm up to ~35.

As a bonus, we compared to quantitative measurement using an ICU monitor and a CVP transducer set. The "peritoneal cavity" here was a saline bag.

Manual manometer (right green stopcock) is leveled with CVP transducer

You’re called to see a patient with rapidly worsening shock.

On the monitor you see the waveform on the left.

An intervention was performed leading to the waveform on the right, within 5 min.

What’s the problem?

What improved it?

#HemodynamicsWaveformChallenge Oh and btw I’ll give the case conclusion and explanation tomorrow so there’s enough time to accumulate some crowd answers and wisdom!

🚨New #OpenAccess Article 🚨

New review article highlighting key points in fluid resuscitation for septic patients, on the wards or perhaps on the verge of needing ICU.

I admit, not without agenda (⬇️fluid overload)

Freely available through Sept 2: sciencedirect.com/science/articl… A few editorial points:

Most of the evidence presented involves critically ill patients, but the lessons shouldn’t much differ if you have a hypotensive/malperfused patient on the wards.

Without the benefit of vasopressors, it’s difficult to determine how to safely resuscitate

Phenomenally lucky to have @AndreMansoor speak at our Critical Care Conference today on Diagnostic Reasoning. A few take aways that resonated:

1) A thorough diagnostician doesn’t ask every question/ROS or perform every exam maneuver

2) Order tests/labs in anticipation of a finding (rather than a shotgun “see what comes up” approach)

Reflections on a cricothyrotomy:

I wanted to share my personal first experience performing this high-acuity and rare procedure, in the hopes that others will learn from it.

Consider this part reflection, part tweetorial

upload.wikimedia.org/wikipedia/comm… A team member called me to say “We need you at the bedside NOW”, without further details, but with a higher sense of urgency than I’m used to from this person, so I ran to the bedside.

In fact, shortly after arriving my watch asked me if I was starting to exercise

🚨 Multi-part case #Tweetorial
24y man no PMH. 3-4 days myalgias, freq diarrhea. 2L saline given on med floor -> hypox/tachypnea. COVID pend.
A 👍
B RR30-34, SpO2 92% 5L NC
❤️ MAP 90, HR 110s ->150s over 12 hrs
D Avpu
E Anxious
L CRP 58 (ULN 0.9), Cr 1.4 (no baseline), Lact 4.8 WOB is moderately elevated.

What diagnostic manuever do you think is most important at this point?

🚨Crashing Patient Case🚨

72 yo ♀️ to ED with syncope, hypotension. Intubated for hypercap/hypox resp failure. Hypotensive post, tx to ICU.

A Tubed
B FiO2 1.0, 10 ml/kg Vt
❤️ MAP 70 -> 50 -> 30 in mins
D sedate, +cough
E Leaky 22g PIV
U n/a
L WBC 35k, lact 1.7, UA+CXR shown First step?

A case in the age of #COVID19

A 50 yo man with no PMH came to ED with confusion & hypoxemia. Admission CXR shown. Possible COVID+ contact.

A Protecting
B RR 28 SpO2 92% 60% HFNC
C BP 90/65 HR 105, Cap Ref 4 s
D A&0 x 4
E - T 37.9
L CRP 3x ULN, WBC 21 (PMNs)

#Tweetorial On arrival to the ICU he develops shock requiring vasopressors. Abx staretd. Mottling on knees. What's the next step?

Case details to follow tomorrow!

Interesting issue in mechanical ventilation of #COVID19 patients, each one here after >10 days of mechanical ventilation.

How might we monitor for development of this? Time to pay attention to resistance, oft neglected in the age of COVID #ARDS...

#tweetorial #SoMe4MV First step is to examine the flow waveform. In this case a patient in volume control, to observe how passive expiration is changed by changing time constant.

More on time constants here: derangedphysiology.com/main/cicm-prim…

Time for answers! As many of you surmised, this patient is not happy with the current settings.

Also, the ventilator *might* be lying to you about its mode... #SoMe4MV

https://twitter.com/msiuba/status/1224514558984933378

The most obvious issue here is flow starvation. The patient's effort suggests they want a much higher flow and/or Vt. Compare the waveform to the idealized VC waveform of a passive patient. The flow goes below the PEEP baseline!

Time for a new concept: a #zentensivist case report!

A middle aged woman with PMH of HTN is brought to the ED complaining of dysuria, decreased urination, and malaise.

She is hypotensive with MAPs in the 40s initially and receives 4L normal saline with improvement in MAP. 1/x She is admitted to ICU. Dx: septic shock, UTI. You are seeing her 10 hr later.

(Borrowed #ogitorial format)
A ok
B mild⬆️WOB, home CPAP
♥️ MAP 66 no pressor
D avPu
E oliguric (<10 ml/hr)
U Preserved LV/RV fxn
L creat 5.9 from 0.9, UA: pyuria

How do you set up pulse pressure variation (PPV) on the monitor? This, of course, requires an arterial line.

Here, @lillieannamd #CleClinicRespiratory shows us how it's done, quickly, on a Phillips monitor. After, we'll talk about uses wrt preload responsiveness... #tweetorial PPV leverages the changes in preload owing to mechanical ventilation, effectively testing where the pt is on the starling curve. A positive response (threshold 12%) suggests they are on a dynamic portion of the curve.

A new #echofirst #POCUS #medthread CASE!

55 yo woman with hx of metastatic lung CA, known malignant pleural/pericardial effusions presents as a transfer in shock with associated encephalopathy. HR 120s-130s (sinus), cool extremities, MAP 65 on 8-10 mcg/min norepi. O2 4L NC. What are you going to do based on the above image?