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"This reflective writing piece was completed by Dr. Aashish Kalani [...]
This is a 40-year old man status post-liver transplant (several months prior) who has had a complicated hospital course. He is now re-admitted with presumed septic shock (query HAP) and has been intubated for respiratory failure. He's also had a formal abdominal ultrasound commenting on periportal hepatic edema and signs of congestion. Based on the images below what interventions might you make to the team in addition to antimicrobial therapy? The team is particularly worried about right heart failure and elevated right-sided pressures - what do you tell them based on your findings?
This is a 54 yo M who presented with acute hypoxic respiratory failure necessitating intubation and ICU admission. Post-intubation he had a P/F ratio of 54 despite a relatively unremarkable CXR. The PEEP was increased to try to improve oxygenation. A CTPA was ordered which was negative for PE and showed just a small right lower lobe consolidation. Given that the refractory hypoxia seemed discordant with the pulmonary pathology, concern was raised for an intracardiac shunt. A point-of-care TEE was performed including a bubble study. Have a look at the selected clips below and see what you think!
This is a 74-year old gentleman with multiple medical comorbidities who was admitted to the ICU with septic shock and bacteremia. He's had a tumultuous course in the unit and has been difficult to wean from vasoactive agents. Below are two series of images. The first were taken earlier in his stay, while on higher doses of vasoactive agents and more acutely unwell. The second were taken a week later when he was clinically significantly improved and weaned from inotropic support; however, there was concerned that some of his Echo parameters had actually worsened! What are we looking at here, and what's the explanation?
This is a case of a 56 yo F admitted with sepsis and MSSA bacteremia. A CT Head revealed several lesions concerning for septic emboli. She had known chronic significant mitral valve pathology documented prior to her admission. The POCUS team keen to see this pathology and to look for any additional signs of infective endocarditis. What do you notice about the valve on the 2D echo images and what specifically do you see on its colour doppler interrogation?
This is a 78-year old woman admitted a week prior with respiratory failure secondary to CHF exacerbation and COPD; on admission, she had a pleural effusion that was tapped and found to be transudative. She now has ongoing dyspnea in the ICU with increasing oxygen requirements. so the POCUS team was called in to help sort things out.