85 yo M polytrauma from a high-speed MVC. Now recovering in the ICU, still intubated, but over the last few days has had worsening oliguric AKI and is now on 10mcg/min of NE. The POCUS team was asked to perform a “volume status” assessment. This is one of the most common requests we get. Below is a representative look at a typical set of images we try to acquire to help answer the million-dollar question of whether a patient would benefit from fluids. Have a look at the images below (which, be forewarned, are quite Doppler heavy) and see what you think!
This is a case of a 52 yo F trauma patient with severe traumatic brain injury. She was intubated and transferred to the ICU where, given the severity of her TBI, an intraparenchymal ICP monitor was placed by neurosurgery. The ICP monitor was initially showing an ICP of 10. Overnight, however, despite no apparent clinical change, the ICP waveform was inconsistent and the readings were now showing values around 40-50. We thus performed a point-of-care TCD to help determine whether her ICP was truly elevated or whether the ICP monitor was giving spurious information. Have a look at the following images. Do you think the TCD spectral waveform is consistent with markedly elevated ICP?
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?