Health
Medical
Medicine
Nephrology
Patient care
Hypotension
Hemodialysis
Ultrafiltration
ESRD
T2DM
Leg Edema
Central Vein Stenosis
Pericardial Effusion
LV Function
RV Collapse
Pleural Effusions
Collapsing RV
Venous Congestion
Tamponade
Ambulatory Hemodialysis Unit Rounds:
Called to see a patient with hypotension: BP 76/40,🧠 OK, CRT 5 seconds
1st step ➡️🛑Ultrafiltration + 300 ml bolus. BP 90/60
Pt is a middle aged ♂️ w ESRD and T2DM
1/9 🧵
Called to see a patient with hypotension: BP 76/40,🧠 OK, CRT 5 seconds
1st step ➡️🛑Ultrafiltration + 300 ml bolus. BP 90/60
Pt is a middle aged ♂️ w ESRD and T2DM
1/9 🧵
Now 3 kg above Dry Weight.
UF Volume so far: Only 600 ml
🔎📁 Previos HD sessions with no hypotensive episodes
1 week with URI symptoms, 2 days with dyspnea on exertion
On exam: No leg edema, Clear 🫁, JVP hard to assess (hx of multiple CVCs and central vein stenosis)
2/9
UF Volume so far: Only 600 ml
🔎📁 Previos HD sessions with no hypotensive episodes
1 week with URI symptoms, 2 days with dyspnea on exertion
On exam: No leg edema, Clear 🫁, JVP hard to assess (hx of multiple CVCs and central vein stenosis)
2/9
#POCUS:
Pericardial Effusion, Normal LV function, looks like there is some RV colapse
Plethoric IVC, Portal Pulsatility 39%.
A-Pattern on LUS, Small bilateral pleural effusions
🚨⬇️BP + Collapsing RV + Venous Congestion (IVC + Portal Pulsatility) suggests Tamponade!
3/9
Pericardial Effusion, Normal LV function, looks like there is some RV colapse
Plethoric IVC, Portal Pulsatility 39%.
A-Pattern on LUS, Small bilateral pleural effusions
🚨⬇️BP + Collapsing RV + Venous Congestion (IVC + Portal Pulsatility) suggests Tamponade!
3/9
Hepatic Vein Doppler shows characteristic D wave reversal!
Again: This is strongly suggestive of Tamponade!!🚨
4/9
Again: This is strongly suggestive of Tamponade!!🚨
4/9
Also..LV looks very empty. LV walls can get too close together and obstruct the flow of blood!
Obstruction causes blood to speed up! (think of thumb on a hose).
Velocity is 3.5 m/s (very fast) with a gradient of 50 mmHg! This is Hemodynamically significant obstruction!
5/9
Obstruction causes blood to speed up! (think of thumb on a hose).
Velocity is 3.5 m/s (very fast) with a gradient of 50 mmHg! This is Hemodynamically significant obstruction!
5/9
In order to improve obstruction, we need to increase preload of the LV! Pericardiocentesis will achieve this (by relieving RV collapse)
In the meantime, a fluid bolus can be a temporizing measure.
More on the physiology of LV obstruction here:
6/9
In the meantime, a fluid bolus can be a temporizing measure.
More on the physiology of LV obstruction here:
6/9
Gave an extra 300 ml fluid and arranged ICU admission!
Fluid did help: BP now 105/69, gradient improved from 50 to 24 mmHg!
However, liver congestion got worse: Portal Vein Pulsatility now 62%. This is not good, especially since LFTs came back ⬆️⬆️⬆️
7/9
Fluid did help: BP now 105/69, gradient improved from 50 to 24 mmHg!
However, liver congestion got worse: Portal Vein Pulsatility now 62%. This is not good, especially since LFTs came back ⬆️⬆️⬆️
7/9
Pericardiocentesis was performed, this fixed everything!
BP now 153/76.
Portal Vein is no longer pulsatile
Hepatic vein shows no D wave reversal
Gradient is now 4.8 mmHg (Not hemodynamically significant!)
8/9
BP now 153/76.
Portal Vein is no longer pulsatile
Hepatic vein shows no D wave reversal
Gradient is now 4.8 mmHg (Not hemodynamically significant!)
8/9
Learning Points:
🔷#POCUS can help in the evaluation of intradialytic hypotension
🔷Venous congestion ≠ Volume Overload
🔷Tamponade ➡️ Low LV preload ➡️ Obstruction (if predisposing conditions)
🔷Fluids worsen congestion, but can be an adequate temporizing measure
/END
🔷#POCUS can help in the evaluation of intradialytic hypotension
🔷Venous congestion ≠ Volume Overload
🔷Tamponade ➡️ Low LV preload ➡️ Obstruction (if predisposing conditions)
🔷Fluids worsen congestion, but can be an adequate temporizing measure
/END
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