Jonika Weerasekare

@aribindi @joshmcgoo Mixed shock. Oftentimes see CI of 1.4, low SVR, low EF, high pcpw/rap. Norepi + Dobutamine is a reasonable choice here. Was not talking about pure cardiogenic shock.

@JonW1993 @joshmcgoo If you give norepi to a patient with a cardiac index of 1 and SVR of 2000, I don't think you're going to have a good outcome. Not all shock is septic shock...

The most correct answer is to NOT give IVF just because the stem started with “inferior STEMI” I think Epi is a fair consideration l, albeit not listed, though…

@LCDG2026 @NephroP Now we have two ways to measure the cvp 😂

@JonW1993 @NephroP Incredibly important.. good use of a Class III device.

Only device in patient is a pulmonary artery catheter. @NephroP

@ThinkingCC Chronic compensated meth associated heart failure. Baseline Hr 130.

@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

Indeed. If there’s a hemodynamic question, there’s probably an indication for a #POCUS-assisted physical exam. POCUS is a clinical skill, so arguing “clinical skills vs POCUS” is meaningless when it is (should be) a part of your skillset. Let's move past the square wheels!

You get a warning in our health system and a mandatory physician override anytime you order bumex doses exceeding 4 mg… completely nonsensical.

@IM_Crit_ Septal flattening during diastole suggests volume overload (rvvo). Classic teaching is fluids in right sided MI but I fail to see how fluids is going to help someone with rvvo. Answered dobutamine.

ICU - Board Review Qs: 60 yo pt admitted to the ICU because of inferior STEMI. Emergency cath: 100% proximal RCA occlusion treated successfully with stenting One hour post-PCI: dyspnea/anxiety - BP: 94/70, HR: 60/min (sinus). Phys exam: JVD (+), clear lungs, cool extremities

@Kemboy254 @franciscojlk They state that map is a key determinant of msfp. Maybe they shouldn’t be trusted on their vasopressor recommendations

@franciscojlk SSC26 Doesn't not recommend

💙 Methylene blue in septic shock: miracle, myth… or misunderstood tool? We all know the scenario: 👉 Refractory vasoplegic shock 👉 Escalating norepinephrine 👉 Vasopressin, steroids… still hypotensive At some point, the question comes: Should we use methylene blue? ⚡ Mechanism Septic shock = NO-driven vasoplegia Methylene blue acts by: ❌ Inhibiting nitric oxide synthase (NOS) ❌ Blocking soluble guanylate cyclase ⬇️ Reducing cGMP ➡️ Restoring vascular tone 👉 A true catecholamine-sparing strategy 📊 What does the evidence say? Reality check: Use in practice is rare (~0.5% of septic shock patients) Often used as late salvage therapy Dosing strategies = highly variable But RCT signals are interesting: ↓ Vasopressor duration ↓ ICU / hospital length of stay Possible ↓ mortality (low certainty) 👉 Evidence is promising… but still weak 🚨 The clinical dilemma Timing is everything: Early use → potential physiologic benefit Late use → often too late to change trajectory 👉 Current practice is probably backwards ⚠️ What about safety? Potential concerns: Serotonin syndrome (with SSRIs) Pulmonary vasoconstriction G6PD-related hemolysis Interference with pulse oximetry 👉 Most serious effects seen with high doses 🧠 Take-home message > Methylene blue is not a “magic drug” but it may be a physiology-driven adjunct in vasoplegic shock ❓The real questions are: Who benefits? When to give it? At what dose? 🚀 Where we’re heading Ongoing trials (e.g., BLUSH trial) will clarify: ✔️ Early vs late use ✔️ Optimal dosing strategy ✔️ True impact on mortality 👉 This could redefine vasoplegic shock management 💡 Clinical reflection Next time you face refractory shock, ask: 👉 Is this still “fluid + catecholamine problem”… 👉 or already a NO-mediated vasoplegia problem? 📚 Reference Fernando, S. M.et al. Journal of Critical Care, 92, 155353. doi.org/10.1016/j.jcrc…

you need to go further

1/6 Sotatercept in Combined Pre/Post Capillary PH (CpcPH): CADENCE (Gomberg-Circulation 2026) A🧵 (8 min read) But first. 🔹Pulm vasodilators NOT approved for PH with ⬆️ left ♥️ pressures (wedge >15; Group 2 PH). Individualized approach recommended. Humbert (2022) 🔹In group 2 PH (PH LHD), pulmonary vasodilation risks “flooding” the left ♥️ and lungs, d/t ⬆️ wedge and impaired LA relaxation 🔹Studies: no benefit or ⬆️ risks (table 👇🏻)

EMCrit 422 - SSC 2026 Guidelines: The good, the Bad, and the UGLY - a discussion with lead author, Hallie Prescott A fantastic interview on how the SSC guideline sausage was made and the areas I found contentious [#FOAMed for now] emcrit.org/422

@ThinkingCC @franciscojlk @khaycock2 @icmteaching @RafaelOliveLeit @PatientStormDoc “Patients must not be fluid responsive to be in refractory shock” Ok so they have to be in iatrogenic heart failure?

@franciscojlk Uh-oh, people sitting around the table, deciding on a definition, that does not sound like a great idea. A highly heterogeneous situation requires proper and complete bedside assessment. Not an agreed-upon definition. @khaycock2 @icmteaching @RafaelOliveLeit @PatientStormDoc

🤔When does septic shock become “refractory”? We have used the term for years. But until now, we never truly agreed on what it means. A new joint Delphi consensus from SCCM and ESICM finally brings structure to one of the most critical, and most ambiguous concepts in intensive care And the message is powerful: Refractory septic shock is not defined by blood pressure. It is defined by failed physiology. Three key takeaways stand out. ->First, tissue perfusion is at the center of the definition. Not MAP. Not urine output. But persistent hypoperfusion: Elevated lactate Prolonged capillary refill time Even after adequate resuscitation. This is a major conceptual shift: we are moving from pressure-based resuscitation → perfusion-based resuscitation. ->Second, dose matters more than the number of drugs. The consensus highlights a threshold: norepinephrine equivalents > 0.5 µg/kg/min Not how many vasopressors you use, but how much support is required to maintain circulation. This reframes severity in a much more physiologically meaningful way. ->Third, and perhaps most important: Refractory shock requires proof that you did everything right first. Before labeling a patient as refractory, you must demonstrate: 1.Adequate fluid resuscitation 2.Lack of fluid responsiveness 3.Exclusion of other shock types using critical care ultrasound ->Only then, failure becomes “refractory.” There is also what the consensus rejects, and this is equally important: No fixed lactate cutoff No ScvO₂ No urine output No strict MAP threshold Because reality is more complex than a number. 🤓Final definition: Refractory septic shock is persistent hypoperfusion in a fluid-unresponsive patient requiring high-dose vasopressors after appropriate resuscitation and after excluding other causes of shock. Why this matters? This is not just semantics. A clear definition means: Better patient stratification More meaningful clinical trials Earlier recognition of the sickest patients And ultimately, more targeted therapies Because not all septic shock is the same. And the sickest patients deserve a name, and a strategy. 📃Reference Leone M Intensive Care Medicine. 2026. doi.org/10.1007/s00134…

@NephroP Mitral, tricuspid, pulmonic ? Interesting cut.

#POCUS #FOAMed What valves are seen in this image?

@RafaelOliveLeit 15k screened 153 enrolled 🤔

Polymixyn hemoperfusion works in Bayes Wonderland thelancet.com/journals/lanre…

IVC #POCUS ≠ Volume 🔗nephropocus.com/2024/06/17/ivc…

@NephroP But then you have get to get a stopcock 😂 nice image though. if the tip is in RA = fantastic and I’m writing ok to use. Also won’t get so many dang alarms with crrt compared to it being in svc

@JonW1993 or this....🫧

#NephMadness #POCUS quiz of the day: 1⃣ What transthoracic view is this? 2⃣ What is the structure indicated by the arrow? #Nephpearls #FOAMed

@NephroP Good image. That is what I am hoping to see when I place a dialysis line.

@JonW1993 👍