Troponin in HFrEF and Sepsis

Check out @ACCCardioEd’s Tweet: https://twitter.com/ACCCardioEd/status/1085245247234469888?s=09

Cardiogenic Shock

Check out @JACCJournals’s Tweet: https://twitter.com/JACCJournals/status/1113818760790585344?s=09

Lactate in Sepsis

Democratizing Cardiac Hand Held Ultrasound

More and more sub specialties use echocardiography at the POC and bedside. I have attended some of these echo courses during Critical Care Meetings. I have also seen Intensivists go beyond the interpretation that are taught in these classes and I have seen some truly scary conclusions that they draw , thinking they understand fully what they are looking at or measuring.

The wider adoption of hand-held ultrasound is inhibited not by the lack of special training, but more by the attenuation of imaging skills of the non-imaging cardiologist.  Democratizing ultrasound by providing ubiquitous axis devoid of formal studies interpreted by echocardiographers is truly scary.  A hand-held ultrasound performed by somewhat with insufficiency skills is probably worse than no information at all.  Perhaps this attenuation skills will be less marked as the generations of the fellow's in training would have had access to hand-held ultrasounds but your through their careers although, this development would be welcome, we have not seen evidence of it yet.

I have seen truly scary interpretations  in the assessment of diastolic dysfunction for example.  Diastolic dysfunction is grossly and oversimplify divided into 4 grades, but truly classifying the function is extremely difficult, dependent on multiple parameters, and in some cases actually impossible to place the results in a particular class.  Assessment of left atrial pressure which is closely bound to this assessment is even more difficult and should be left to cardiologist with many years of experience in reading echocardiograms.  In particular bedside hand-held ultrasounds will often give fraudulent data.

For example assessment of IVC size and respirophasic changes is useless in patients on mechanical ventilation, yet an assessment is regularly made this way to define filling pressures.

The American College of cardiology has developed multiple algorithms to classify diastolic dysfunction and determine left atrial pressure.  They are not easy to remember and each has variable accuracy [sensitivity and specificity].

See attached article 1 and 2 and my slide presentation.

Critical Care Ultrasound Handbook

For those at the bedside this book may come in handy , also the BLUE protocol on lung ultrasound is well explained

 CAC Book from the Fluid Academy website

Back to the Drawing Board on ARDS

Prone positioning in severe ARDS now debated: some feel it can be more harmful than beneficial - has the pendulum swung? If so, there is no particular therapy left for ARDS - discussions at @ISICEM - #ISICEM19

— Jean-Louis Vincent (@jlvincen) March 6, 2019

I suspect with further studies we will see regression to the mean ....and proning likely may improve oxygenation but not mortality , similar as we saw in the ARDS Network with higher Tidal Volumes : improved oxygenation with higher tidal volumes but over time a higher mortality 

The Troponin Leak During Sepsis

Practitioners may be able to influence the risk of postinfection myocardial infarction if they remain mindful of the increased risk of myocardial infarction during and after acute infections and if they do not dismiss elevated troponin levels as “troponin leak.” Among patients with acute infection who have clinical indications for statins and aspirin, these medications should be continued (if the patient is already receiving them) or may be initiated if no contraindications are present.

Published in NEJM