Treatment of End-Stage Heart Failure – Link to EMCrit Podcast 240 “Renal Compartment Syndrome And It’s All About the Venous Side”

I’ve been working on developing a deeper understanding of diastolic dysfunction and of congestive heart failure in general [see Diastolic Dysfunction Minicourse
Posted on February 15, 2019 by Tom Wade MD].

And then I listened to this awesome podcast, EMCrit Podcast 240 – Renal Compartment Syndrome & It’s all about the Venous Side and We’ve Been Fracking it up for Years – February 10, 2019 by Dr. Scott Weingart of EMCrit. In the podcast Dr. Weingart interviews intensivist Dr. Phillipe Rola of Thinking Critical Care.

Here is Dr. Weingart’s introduction to the podcast:

So what we’re going to talk about today is the venous side; the often neglected often ignored venous side.

And we’re specifically going to talk about a concept of the renal compartment syndrome. For ages I was taught, when I was a critical care trainee that you have to preserve the MAP to preserve the kidneys.

But it turns out, just like every other compartment syndrome it’s not the MAP; it’s not the diastolic blood pressure, it is the perfusion pressure meaning it is both the arterial pressure supplying the kidney and you have to subtract the venous backflow against the kidney.

And it is the two together that determine the perfusion pressure and that is what determines whether or not the kidney lives or dies.

And so the concept of giving fluids may increase cardiac output if the patient is volume responsive but at the same time it is going to increase the venous back pressure.

And the net, depending on the patient’s hemodynamic milieu, may be to make the patient worse. I think it often does make things worse.

And that is really the subject of today’s podcast. Really this is just one road to get to a place that I think if you listen long enough to EMCrit you’re going to get to. But there are many different patient different scenarios that you could use get to the same place.

The one we’re going to go into now is maybe the most cleanly evidence based one which is management of CHF patients.

It is just going to be Phillipe telling the story of one patient that caused him to radically shift where he is spending his time. He has actually started an end-stage CHF clinic because the care that he can provide may be very different from the care his colleagues are providing.

And at 6:20 Dr. Rola begins his talk:

So today I’m going to speak a little bit about a case that actually became the index case for the startup of our advanced CHF clinic.

And I think it is a really interesting case and really displays a lot of the usefulness that some of the markers of echographic venous congestion can do clinically for you.

Dr. Rola’s patient is a 70 something man with severe cardiomyopathy, cirrhosis, massive ascites and was thought to have hepato-renal syndrome. He was thought to be terminal and Dr. Rola was consulted to perform a palliative drainage for ascites. The case goes on from there.

The podcast is really about Dr. Rola’s innovative approach to the treatment of end-stage heart failure using his state-of-the-art POCUS skills.

And here are two of Dr. Rola’s posts  in which he explains how he uses POCUS in heart failure:

In addition to listening to the great podcast and the above posts, be sure to also review Dr. Rola’s posts:

And listen to Dr. Rola’s two great podcasts, Is POCUS the new PAC??? A Chat with Jon-Emile Kenny from Thinking Critical Care, Febuary 12, 2019.

And finally, be sure to review all of the thoughtful reader comments that follow the EMCrit Podcast #240. Every EMCrit podcast has outstanding reader comments that are worth reviewing.

Additional Resource:

Excerpts From “A Simplified Ultrasound Comet Tail Grading Scoring to Assess Pulmonary Congestion in Patients with Heart Failure” Posted on February 21, 2019 by Tom Wade MD.


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