Newest Member of the EMCrit Team: Phillippe Rola
Internist-Intensivist in Montreal, Canada, Mad Sonographer, Proud Daddy and Husband, and sometimes jiujitero.
Editor-in-Chief of ThinkingCriticalCare.com
POCUS Portal Vein from the Case
More on the Discussion in the Podcast on Thinking Critical Care
H&R 2019 Conference
Additional New Information
More on EMCrit
- EMCrit 286 – The Venous Side Matters Too with Phil Rola
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This is a great topic. First of all, I know Phillip and not only is he a quite a brilliant guy, but in addition he is a genuinely a nice person when you meet him. Phil is dedicated to excellence in education and pushing the quality of critical care forward, a pioneer. He knows POCUS and its application to resuscitation more than I’d guess 99.99% of doctors out there who think they know POCUS. The first thing I’d bring up is that probably what Phil’s case is NOT is the SCAPE patient. This is a different pathophysiology and I think… Read more »
Hi Korbin,
Thanks for the sharing. I am quite intrigued by your using dobutamine/milrinone in the congestive state with low CO. I think it makes perfect physiological sense but I do worry about the patient’s BP. Do you see a significant drop in BP in your experience?
I don’t commonly see hypotension when I do this, in fact the BP often increases a bit. I should mention that before considering an inodilator, I always have an a-line in these patients and I’ve done a bedside ECHO confirming a low CO, high CVP, and a high calculated SVR at the very minimum. Because I have the a-line, I know immediately if the BP is dropping and I can intervene appropriately. Even if the MAP drops a little, if the IVC starts collapsing a bit, the CO improves, the SVR goes down, and the patient’s skin warms and drys… Read more »
Thanks Korbin! As usual, a Korbin comment is often what makes the post. Or at least, many of my posts, which are literally cuts and pastes from the smart guys I have had the good fortune to surround myself with. You are absolutely correct that this does not apply to the SCAPE patient who is usually not in a state of venous congestion initially. As you stated, indeed the intrarenal venous doppler is important and illustrative, I just didn’t have .a machine that could do it well when I first met this particular patient, and it is a more challenging… Read more »
I hope everyone here realizes Korbin is doing all this in the ED. I doubt most ‘upstairs care’ is on par with his ‘downstairs care’!!!
Thanks for the great podcast. As an emergency physician, I have been interested in using portal vein pulsatility for determining fluid responsiveness in hypotensive patients (without or without chronic liver and heart dysfunction). Since there is obviously a lot of debate about the utility of IVC, LVOT VTI, and other sonographic measurements that can be factored into the decision of when to give fluids vs pressors – I am curious how this might fit in. I have two main questions 1) Could the absence of pulsatility indicate volume responsiveness since it reflects right sided pressure and 2) Would you expect… Read more »
Hey Mike! Thanks for listening! So you raise some important clinical questions, which are quite dear to my resuscitationist’s heart. The quest for volume responsiveness has become quite popular, and, to be honest, is not something I buy into anymore. First of all, because it usually leads to well-meaning attempts to eradicate said volume-responsiveness using fluid boluses, which by default, results in a CO-maximizing strategy (though usually labelled optimizing). Those studies were well conducted in the 80’s and 90’s showing that trying to treat shock by normalizing or supra-normalizing DO2 did more harm than good. Secondly, it is important to… Read more »
Fascinating case!
would like to know if there is a some data about it.
its frequent to have cirrhotic patients been treated as hepatorrenal syndrome,
but already full of edema and people keep going with albumin.
Hi Rodolpho and thanks for listening. Yes, while most often cirrhotics tend to be on the low intravascular volume side, I have seen some get juiced up pretty good, and certainly, especially the cardiac cirrhotics, certainly warrant a venous POCUS look before blindly giving albumin as a well-meaning but misguided effort to avoid hypotension following large volume paracentesis.