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…

@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.

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

@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.

@aribindi @fersaurin Yeah ok.

@ThinkingCC @fersaurin I have never wedged in my life. Its useless. Look, if someone has the resources to spend 30 minutes getting echo tech quality views, change the inotropes, and then come back and do it again, they probably aren't learning much from this question.

@_Coati_ @Inamanotherapy @khaycock2 @NephroP Absolutely.

@Inamanotherapy @khaycock2 @NephroP @ThinkingCC This is a false dilemma, it’s not either or, you can consider POCUS to be a component of or extension of the physical, not necessarily a replacement of it. That would be like saying getting imaging or labwork of any kind is pointless because the clinical exam is sufficient.

For the Specialist not trained in the Gen Med here is an important but overlooked tip for your patient's Creatinine problems: If the BUN/Creatinine ratio is >20- Give Fluids. The Creatinine will normalize after 24 hours If the BUN/Creatinine ratio is <20- Call the nephrologist. This is not your patinet to treat !

@Inamanotherapy @khaycock2 @NephroP Every time i examine. Pocus is just part of a comprehensive exam. Touch, cap refill, but i won’t use a surrogate (S3/4 or percussing heartt borders) when i can look and see…

@khaycock2 @NephroP @ThinkingCC Okay. Out of curiosity, When was the last time you used clinical skills to Examine a patient?

@azeemrathore_ @wkcmd Never fluid for a dilated RV with septal shift and elevated JVP. I would have norepi on the ready, probably already infusing low dose, have to defend the map, but inotropy is the main tx here, if fails, mcs.

@ThinkingCC @wkcmd If you start dobutamine and get hypotensive, do you go with levo or fluid? Also could you make an argument for milrinone here too? Truthfully, I almost always seem to be started for patients in cardiogenic shock, I rarely see milrinone just anecdotally speaking.

@Jorgeheartshock Keep at it!

@ThinkingCC It’s so 🧑‍🔧 in IM or cardiology minds, but that’s why we need to keep physiology and PV loops in mind, as contractility is sometimes an independent measure, as in Ees. I have trouble my self explaining this to our residents RV doesn’t mean fluids. 🔥🫡

@kenza06043531 Hmm ok.

@ThinkingCC Yes

@aribindi @fersaurin Like I said, I love and use swans all the time. But they are very limited diagnostically. You need focus. And elevated wedge can be due to many things in the swan cannot differentiate. Yeah.

@fersaurin @ThinkingCC Swans have their problems, but at least no one can doubt the numbers on the monitor and xray confirming placement.

@aribindi @fersaurin @IM_Crit_ is exceedingly skilled with a probe, I’ve seen this myself. If we were talking about a random person, then the next step would be proper focus confirmation by a skilled practitioner.

@fersaurin @ThinkingCC Because the LV may not be underfilled and RV may not be distended. You often just have someone bad at POCUS getting a bad view, or mixing up the ventricles, and are making decisions with bad data.

@hossamelbahrawy This RV needs help. Interface 4 is completely uncoupled, and this has resulted in secondary failure of interface 1. This needs inotropic support, inhaled vasodilators ok, but given the pathology, this is unlikely to help because the primary problem is not pulm htn.

in reality, that can't be an “either/ or” situation. In the abscence of Milrinone, dobutamine + fluids ±norepi are sufficient in many scenarios

@wkcmd We don’t have profoundly depressed aortic pressure in this case. DBP is 70. Indeed they may or may not result in improved RV function, but then its time for MCS. This is cardiogenic shock.

@ThinkingCC Pure inotropes like dobutamine and milrinone, while effective in some cases, may not reliably augment profoundly depressed aortic pressure and can worsen hypotension by failing to increase LV preload.