Philippe Rola

Last few days for early bird! Join us in Montreal next september! #HR26 Nothing quite like it... thinkingcriticalcare.com/2026/01/16/fou…

Just putting a feeler out there...Anyone up for #VExUSinMilan (Italy) next november? (did I mention participants will get to meet @khaycock2 in the flesh?)

@YubSedhai oh yes absolutely different animals!

@ThinkingCC I fully understand the concept, I was just highlighting the fact that are failure in setting of proximal RCA MI, and acute and chronic RV systolic dysfunction on a background of chronic pulmonary hypertension are two different physiological constructs!!

It is terrifying that 33% gave fluid to a struggling RV with an underfilled LV. Terrifying.

RAPID ECPR: Revolutionizing Accelerated Percutaneous Initiation and Deployment of ECPR: single center process and outcomes - Journal of Cardiothoracic and Vascular Anesthesia jcvaonline.com/article/S1053-…. Excited to finally share this data, really proud of the incredible Mayo team!

@GeorgesStPierre Can’t agree more! Can’t stop!

We don’t stop training because we get old. We get old because we stop training

Ping @TrinaAugustinMD see comments😉

@The_Nanashi_O @aribindi Absolutely. And there are, like anything else, many levels, each clinician has to understand the limits of their knowledge and skill. But at every level, there are valuable, relatively low hanging fruit that can benefit patients greatly.

@aribindi @ThinkingCC Similar to ECG interpretation, acute/critical care echocardiography boils down to interest and motivation — less to do with specialty.

@YubSedhai Not with a dilated RV and septal shift. RV limit has been hit. Additional increase in MSFP will only worsen ventricular interdependance. The only RV failure that benefits from fluids is the patient who is concomitantly hypovolemic.

@ThinkingCC Philippe, -RV failure from RCA MI ≠ RV failure in chronic PH. -PH → high PVR →Chronic dilated and weak RV-> fluids can worsen physiology and outcomes. -RCA MI → normal PVR → may tolerate volume better than folks with high PVR.

@aribindi @The_Nanashi_O We’ll just agree to disagree. You are clearly anti-pocus, and that stance is to me, a massive step backwards. Are there educational challenges? Sure. But limiting ultrasound to “pro” exams will harm more than help.

@The_Nanashi_O @ThinkingCC Are there expert crit care docs who can reliably get echocardiographer level views and data? Sure. But its not reliable. My point is not that echos are unreliable in sick patients, it is that the average person doing POCUS can't get reproducible, safe results.

@adventurelolo We all have those haunting cases my friend… comes with the territory.

@ThinkingCC This guy was only in his early 40's and had a family--he ultimately coded again and didn't make it and it haunts me to this day.

@adventurelolo Yup we’ve been battling these reflexes for years but culture is hard to break…

@ThinkingCC Will never forget a residency ICU pt we got after he coded from getting multiple fluid boluses for hypoTN. Attending POCUSed him and showed us how his RV was an overfilled hypokinetic mess and how just reflexively giving fluids for low BP without knowing their hx was dangerous.

@aribindi @fersaurin That is a fantastic luxury. I envy ease of ecmo access.

@ThinkingCC @fersaurin To be fair, I suppose I see this most commonly coming off of CPB. We play with the inotropes and lock in a good regimen with the ability to go back on immediately if needed.

@aribindi @fersaurin I would try inhaled milrinone but the risk with IV would be to worsen sam without improving lvedv.

@aribindi @fersaurin In dynamic lvoto? With a crap rv ? I think inotropes would be, well, lets say a hazardous choice.

@JonW1993 Totally agree with your point. 5 though? I would think that may have been underestimated by angle… have not seen many 5’s with sub 3 crts…

Classic auscultation signs really have limited utility in high resource health care settings. Important to combine pocus with traditional physical exam and clinical reasoning. Have seen countless patients with VTIs of 5, low CI but ok cap refill and adequate organ function

@The_Nanashi_O @aribindi That is a fairly pathognomonic statement.

@aribindi @ThinkingCC What could've been a reasonable point was marred by "none of you are as good at POCUS as you think you are". Do you see how utterly unhelpful that statement is?

@Nadannzeigmal @khaycock2 You got it!

@ThinkingCC @khaycock2 Not a doctor here! But DBP 70, HR 60, IVC 2,5 -> no fluids -> Inotropes!

@aribindi @fersaurin Indeed SAM is the best example. You would not go with inotropes or rate control or volume but would push me towards MCS instead.

@ThinkingCC @fersaurin If the patient has HOCM, sure, but you'll generally get that off the hx. How would concomitant LV dysfunction change your management in this case? Or better yet, lets say the patient has SAM and RV dysfunction and volume overload as defined here. What would you do differently?

@aribindi @fersaurin Disagree with a. Agree with b but that could be compounded with dynamic lvoto you won’t see, or concomitant LV dysfunction. Inherent weakness of swan is the non linear relationship between P and V. Combine w pocus for real power.

@ThinkingCC @fersaurin It is better for the average doc in practice to focus on getting good with interpreting and using swan numbers than relying on pocus. In this scenario, a high cvp and low papi off the swan will easily tell you you are going into RV failure.

@DrRJWebb Yup

@ThinkingCC ‘RV is preload dependent’ Not this one. This one is preloaded. We’re past that.

@aribindi @fersaurin No argument there. Not sure what the point is tho. Community doc here.

@ThinkingCC @fersaurin For all the doctors out there in the community, who don't have a fellow to answer pages while they mess around, I have seen bad ultrasound interpretations literally kill patients. Bad decisions based on incomplete views can be lethal.