iiinova — where your digital self keeps evolving

Not really, as long as you’ve got a segment aligned vertically on your screen (ie you don’t want to be seeing a short-axis cut of it)

ccusinstitute.wixsite.com

So: want to learn more about portal venous doppler and #VEXUS? Dr Curro Mirrales is speaking all about Portal Venous waveforms at #HR25 - come learn from the best!! May 22-23 in Montreal 🇨🇦. Grab your spot today!!! ccusinstitute.wixsite.com/ccus/events/...

HR2025 - Fluid Tolerance, all Things VExUS & Shock Hemodynamics | CCUS.meducate

For more info and for the preliminary schedule, please click here or copy/paste: https://thinkingcriticalcare.com/2024/06/05/hr2025-the-hospitalist-the-resuscitationist-montreal-may-21-24-2025-hr25/

010

Portal vein Doppler tracks volume status in patients with severe tricuspid regurgitation: a proof-of-concept study - PubMed

Likewise, their IVCs and hepatic veins (because of the proximity to the IVC) will always be abnormal. By moving farther away to the portal vein, we can get a better reflection of organ congestion with diuresis, as was elegantly demonstrated in this recent paper pubmed.ncbi.nlm.nih.gov/38734970/

pubmed.ncbi.nlm.nih.gov

This proof-of-concept study suggests that PVD is the only sonographic marker that can track volume removal in severe TR, offering a potential indicator for decongestion in this population. Further int...

131

3. It's the most useful in those challenging patients with severe TR The R-heart failure/severe TR patients are often the most challenging to assess in terms of congestion. Many of them will ALWAYS live at a high CVP.

2. It's the easiest to interpret Unlike the hepatic vein, which can be misleading in the absence of EKG gating, the portal vein is easily interpreted You can use calipers to measure pulsatility fraction; but you can also use the eyeball method to assess mild vs moderate vs severe pulsatility.

You should see a nice vertically-aligned segment of the portal vein pop into view; easily recognized by its bright hyperechoic borders and hepatopetal blood flow (which will look RED on colour doppler).

1. It's easy to obtain Unlike the intra-renal veins, which can be elusive even to the most experienced scanners, the portal vein is usually easily identifiable. From R coronal plane in the mid-axillary line, with your liver/kidney in view, fan or slide your probe in the anterior-posterior plane.

131

Katie Wiskar @katiewiskar.bsky.social · 19/02/2025

A quick #VEXUS thread 🧵- 3 reasons why the portal vein is the most useful single venous doppler waveform 🥇 (if you're only going to do ONE site to look for venous congestion, this is probably the most useful one!) #emimcc

32215

In the wise words of @drfreeze.bsky.social - "The goal is to titrate PEEP to the triad of best compliance, best oxygenation, and best RV function" 🫁🫀👍 An intensivist, physiology enthusiast, and all-star medical educator, he'll be speaking at #HR25 all about next-level Non-Invasive Ventilation ✨

171

Katie Wiskar @katiewiskar.bsky.social · 19/02/2025

Non-invasive positive pressure ventilation - BiPAP and CPAP, for example - can be a bit of a black box to most of us ⬛️ Once it's started, the nuances of how to adjust it to optimize each patient's physiology takes skill, experience, and often, a bit of trial and error 🔎 #emimcc

181

Katie Wiskar @katiewiskar.bsky.social · 16/02/2025

Yeah definitely lots of local variation; and ICU carries its own set of needs due to the extremely high acuity. I think many of these are fairly universal though!

I love that question - “can anyone think of anything we’re missing?” Medicine is a team sport and I value feedback from everyone!

051

There is lots more to be said here, so I'm curious to hear from others: what are your top tips for efficient rounding? 👩‍⚕️📋⏰💉🤓 #MedSky #skeetorial #emimcc #InternalMedicine

020

Especially early on in training, I would MUCH rather see trainees who are very thorough in their rounding, even if they take slightly longer; than those who race to finish and miss important details.

10. For early trainees: don't sacrifice thoroughness for efficiency All this being said: a huge part of rounding efficiency comes from experience. As you become more comfortable managing common problems and your knowledge base expands, so too will your rounding efficiency 🧠

The patient admitted with pneumonia who had half a second of brief tingling pain in their big toe, now resolved - probably doesn't need an urgent CT scan. The vasculopath admitted for heart failure who has new colour change and pulselessness in their foot, in contrast, certainly does!

9. Not everything has to be an issue This comes largely with experience and a growing knowledge base, but knowing when something is an issue that requires further (possibly urgent) investigation, and when something can be safely deferred or observed, is a key skill 🗝️

8. Batch work This is not always possible for patient care and flow reasons, but I do find it helpful ✅ For example: I will often save my discharge summaries and do these after completing my rounding on all my patients.

But if you can, try to set aside focused work periods and minimize interruptions that are not time-sensitive ⏰ Having a dedicated time to discuss with Allied Health, for example; or a system whereby nurses can leave non-urgent messages for the care team (without a phone call/page), can be helpful

7. Avoid interruptions* I know, I know - this can be next to impossible in a hospital setting, especially in certain environments. (Hats off to all my EM friends who manage near constant interruptions!)

When I round the next day, I can quickly and easily see my proposed plan. That's not to say that your plan can't change from day to day, but it makes it much easier if you've already done the initial cognitive legwork.

6. Make life easier for your future self When I am writing my Assessment/Plan section, I try to think ahead for each issue. What will the next step be? If X happens, what will I do? What about if Y happens? 🤔

You do not have to restate every single investigation since admission. You do not have to rewrite all the information you've included earlier in your note. Be complete, but be concise: edit your note frequently. State the current issues, DDx for these, and next steps.

5. Less is more A very common mistake I see trainees make is the ESSAY of a rounding note, especially the Assessment/Plan section (made even worse by the copy/pasting of prior notes). There is a temptation to include every piece of information in your Assessment/Plan section - resist this! ❌

4. Get to know your EHR Electronic Health Records are supposed to make our lives easier. Most have areas of frustration, but becoming facile with the time-saving features of your EHR can really boost your efficiency ⏫ For example: templates for common text, shortcuts to pull in common labs, etc

As much as you can, flesh out your issue and priorities before entering the room, so that you can make sure to ask the key questions and examine your patient appropriately. This means prepping your note and issues list, and processing the patients results, before stepping in the room.

3. Prep before you enter the patient room It's a classic medical student move (we've all been there!): going back into the patient room 4-5 times because you've forgotten to ask them something important 🤦‍♀️

...by mentally processing everything twice: the first time when you see the result; and the second time when you actually round. I prefer to quickly (<10min) check for critical labs & follow up on any urgent investigations. Otherwise, I will process results as I'm actually rounding.

2. Don't do work twice This may be controversial, but I am not a fan of the extensive "computer rounds before actually rounding" scenario 💻 If you are taking 30min+ to look up every patient's new investigations, without actually completing your rounding, you are wasting time...

1. Prioritize Take the first 5 minutes to set yourself a list of priorities 📋 You should know ahead of time who needs to be seen first. For me, this list is usually (in order): - sickest/deteriorating - new-to-me patients - time-sensitive procedures/investigations/discussions - discharging

150

Katie Wiskar @katiewiskar.bsky.social · 09/02/2025

We've all been there: a Saturday on call in the hospital, with a list of 30 patients to round on 😵‍💫 Ward rounding can seem like an endless task - but it doesn't have to be! ⏰ Here are my top 10 tips for ward rounding efficiency 🧵- #emimcc

4143

Thank you!! Totally agree - Lung US is such a game-changing (and relatively accessible!) skill 👌🏻

010

Reposted by Katie Wiskar

Rosie Baruah @rosieicm.bsky.social · 08/02/2025

Love;y thread with take-home top tips Honestly, learn lung US. It is *such* a useful skill in the assessment of the critically ill!

1124

ubcimpocus Tutorials — UBC IM POCUS

12/ Thanks for reading! 🙏 For more on #LungUltrasound, including image acquisition and common pitfalls - check out the rest of the videos on the ubcimpocus site ✨ Drop you #LUS pearls here! #MedSky #Skeetorial #POCUS #LungUltrasound www.ubcimpocus.com/ubcimpocus-t...

ubcimpocus.com

11/ Of course - it goes without saying! - that all of these ultrasound findings should be incorporated with the rest of the clinical picture to help you reach a decision 🩺

191

10/ Finally, we can look at other associated pathology. In HF, we will often see other features such as bilateral simple pleural effusions; plus supportive cardiac findings. In inflammatory/infectious causes, you may see unilateral consolidations, dynamic air bronchograms, shred signs, etc.

160

9/ B lines arising from pulmonary edema should be bilateral, symmetrical, and in a dependent gradient (ie. most prominent at the bases). B lines from infectious/inflammatory pathologies, on the other hand, are often asymmetrical, non-gravitational, and may display skipped or spared areas.

150

8/ Next, we can look at the distribution of B lines across the thorax. Note that this is why we always have to scan representative areas of BOTH sides of the chest - you cannot just take a single clip and call it pulmonary edema‼️

7/ In contrast, with infectious/inflammatory pathologies, you will see B lines which are NOT homogenous throughout the interspace. You may see all the B lines arising from a single point on the pleura; or even A lines throughout part of the interspace.

180

6/ Next, we can look at the distribution of B lines across the interspace. Pleural fluid fills interlobular septae in a predictable and regular way; which generates B lines that are evenly spaced throughout the whole interspace.

170

5/ In contrast, B lines arising from an irregular, ragged, interrupted pleural line are more likely to be from infectious/inflammatory pathologies. (If you want to know WHY this happens - check out the video above!👆)

160

4/ And there are several ultrasound features that we can use to tease apart these two types. First: we can look at the pleural morphology. B lines arising from a smooth, crisp, uniform pleural line are more likely to be from cardiogenic pulmonary edema.

180

3/ Broadly speaking, we can divide B lines into 2 categories. B lines arising from: - Cardiogenic pulmonary edema 🫀 vs - Infectious/inflammatory pathology 🦠 The latter includes things like atypical or viral pneumonias, ARDS, interstitial lung disease, lymphangitic carcinomatosis, etc.

180

2/ Remember that B lines are generated because of something filling the interstitium & interlobular septae Fluid can fill these spaces; but so can other things! Pus, cells, fibrosis, blood - anything that can give you an interstitial pattern on a chest X ray can give you B lines on ultrasound.

150