Hemodynamics in CCU

[intmed2014]

Any recommended resources to understand hemodynamics in CCU. Particularly RHC/Wedge Pressures/IABP. Previous threads in cardiology section have Cardiovascular Hemodynamics for the Clinician and Textbook of Clinical Hemodynamics but I think these are too indepth for an IM resident. Any concise texts or websites would be recommended.

I appreciate any input

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[karayraisu]

Ask around and see if anyone in your program has the MGH CCU guide. I don't have it myself but we had copies of it on our CCU computers and that little pdf (it's about 100 pages) was a lifesaver. I learned EVERYTHING about Swans from that guide.

 

[smartparts]

Everything I ever needed to know was in Pocket Medicine. For further reading, try Marino's ICU book.

 

[deleted547339]

Ask around and see if anyone in your program has the MGH CCU guide. I don't have it myself but we had copies of it on our CCU computers and that little pdf (it's about 100 pages) was a lifesaver. I learned EVERYTHING about Swans from that guide.

Everything you need to know about Swans = nothing?

 

[IMreshopeful]

Everything you need to know about Swans = nothing?

My heart failure attendings would beg to differ - there's a lot of utility to their use (some prefer it more than others) in advanced heart failure. Your exposure in the ED isn't going to teach you that.

 

[deleted547339]

My heart failure attendings would beg to differ - there's a lot of utility to their use (some prefer it more than others) in advanced heart failure. Your exposure in the ED isn't going to teach you that.

People liking something doesn't mean there's utility.

 

[jdh71]

My heart failure attendings would beg to differ - there's a lot of utility to their use (some prefer it more than others) in advanced heart failure. Your exposure in the ED isn't going to teach you that.

I haven't met a heart failure/transplant doc that didn't think they were the ****ing tits.

Maybe in their capable hands with pure heart failure it improves outcomes. But I doubt it and I don't think it's really been studied. A heart failure patient sick enough to need a swan is in a lot of trouble - you can watch the numbers but it is relevant??

The early 2000's killed the swan in the medical and surgical ICU. Maybe the surgeons and intensivists were all just barbaric idiots when it came to them compared to an expert heart failure cardiologist, but I'm skeptical of that type of claim.

The bottom line is I think the numbers make us feel better. I don't put them in, but if I have one available in a patient I'm helping with I use the data. I feel better about my decisions, but the data says my feelings about the data doesn't equal outcomes. It's too bad becuase I felt good about weaning the pressor and starting some low dose dobutamine. Hm.

 

[deleted547339]

My heart failure attendings would beg to differ - there's a lot of utility to their use (some prefer it more than others) in advanced heart failure. Your exposure in the ED isn't going to teach you that.

JDH said it better. This has nothing to due with my scope of practice as an EM doc (I'm starting my critical care fellowship in July BTW), it has everything to do with evidenced based medicine.

 

[intmed2014]

I work with interventional cardiologists, surgeons and intensivists that some would consider "barbarians" lol. High volume STEMI center with TAVR, VADs, ECMO, transplant. Although a lowly medicine resident like myself is not alone in CCU, it would be nice to know what is going on.

 

[intmed2014]

Also, thank you for the suggestions!

 

[Instatewaiter]

I haven't met a heart failure/transplant doc that didn't think they were the ****ing tits.

Maybe in their capable hands with pure heart failure it improves outcomes. But I doubt it and I don't think it's really been studied. A heart failure patient sick enough to need a swan is in a lot of trouble - you can watch the numbers but it is relevant??

The early 2000's killed the swan in the medical and surgical ICU. Maybe the surgeons and intensivists were all just barbaric idiots when it came to them compared to an expert heart failure cardiologist, but I'm skeptical of that type of claim.

The bottom line is I think the numbers make us feel better. I don't put them in, but if I have one available in a patient I'm helping with I use the data. I feel better about my decisions, but the data says my feelings about the data doesn't equal outcomes. It's too bad becuase I felt good about weaning the pressor and starting some low dose dobutamine. Hm.

A lot of the critique of these studies is based around a few things:
1) They weren't studied in the right population- in all comers (sepsis, post op blood loss, distributive) of shock you don't need a swan. If you just had surgery or are febrile to 40, unlikely that you're going to benefit with a swan. But in those who are undifferentiated with confusing hemodynamics or are severely decompensated it probably does help.

2) People who aren't used to swans can't use them appropriately. The swan doesn't help if you can't milk it for its data.

3) It is almost impossible to show better outcomes with a diagnostic tool. Why do we use chest X rays in all comers- bet if you did the study there wouldn't be a positive signal. I bet the same thing with echos. This does not mean these things don't have utility and won't change your management just that just that it is hard to prove a signal especially when studied in the wrong patient population.

 

[Instatewaiter]

JDH said it better. This has nothing to due with my scope of practice as an EM doc (I'm starting my critical care fellowship in July BTW), it has everything to do with evidenced based medicine.

You having an opinion on swans is like me having an opinion on what type a stitch a plastic surgeon should throw...

It should tell you something that the guys who deal most with hemodynamics are the ones who find the most utility in swans and RHC.

 

[Instatewaiter]

Any recommended resources to understand hemodynamics in CCU. Particularly RHC/Wedge Pressures/IABP. Previous threads in cardiology section have Cardiovascular Hemodynamics for the Clinician and Textbook of Clinical Hemodynamics but I think these are too indepth for an IM resident. Any concise texts or websites would be recommended.

I appreciate any input

Now that I'm off my soap box. To answer your question the best book is: Ragosta- clinical hemodynamics. It is a relatively quick read. You could get through it in a day or 2.

 

[jdh71]

A lot of the critique of these studies is based around a few things:
1) They weren't studied in the right population- in all comers (sepsis, post op blood loss, distributive) of shock you don't need a swan. If you just had surgery or are febrile to 40, unlikely that you're going to benefit with a swan. But in those who are undifferentiated with confusing hemodynamics or are severely decompensated it probably does help.

2) People who aren't used to swans can't use them appropriately. The swan doesn't help if you can't milk it for its data.

3) It is almost impossible to show better outcomes with a diagnostic tool. Why do we use chest X rays in all comers- bet if you did the study there wouldn't be a positive signal. I bet the same thing with echos. This does not mean these things don't have utility and won't change your management just that just that it is hard to prove a signal especially when studied in the wrong patient population.

I rest my case.

 

[deleted547339]

You having an opinion on swans is like me having an opinion on what type a stitch a plastic surgeon should throw...

It should tell you something that the guys who deal most with hemodynamics are the ones who find the most utility in swans and RHC.

Ouch.

It does tell me something. It tells me they like the warm and fuzzies they get from more data over using literature.

 

[Instatewaiter]

Ouch.

It does tell me something. It tells me they like the warm and fuzzies they get from more data over using literature.

A similar parallel is that PE protocol CTs do not improve mortality in PEs. Why do we use them? Because they are a reasonable diagnostic modality which may change our management and very quickly and easily gives us the right diagnosis. Swans are similar in that regard.

For that matter, name any diagnostic modality which in a general population change outcomes...

Also, swans are teh ****ing tits

 

[jdh71]

A similar parallel is that PE protocol CTs do not improve mortality in PEs. Why do we use them? Because they are a reasonable diagnostic modality which may change our management and very quickly and easily gives us the right diagnosis. Swans are similar in that regard.

For that matter, name any diagnostic modality which in a general population change outcomes...

Also, swans are teh ****ing tits

I again rest my case.

 

[deleted547339]

A similar parallel is that PE protocol CTs do not improve mortality in PEs. Why do we use them? Because they are a reasonable diagnostic modality which may change our management and very quickly and easily gives us the right diagnosis. Swans are similar in that regard.

For that matter, name any diagnostic modality which in a general population change outcomes...

Also, swans are teh ****ing tits

No. The reason CTAs aren't making waves is because you're over diagnosing sub segmental PEs and anticoagulating people that don't need it. We're helping some while harming others. The reason you don't see a change in swans is because they just give you a pretty output parameter to stare at.

 

[inspirationmd]

I will say the Heart Failure folks seem to love them. I just started spending a bunch can of time in the cardiac icu as part of my critical care fellowship so I haven't formed a full on opinion about them in this particular patient population yet.

Definitely wish they would do less "guy needs a swan" and then walk away as opposed to putting it in themselves.

Also them wanting a milrinone gtt and a low dose beta blocker still seems a little weird to me. But again we will see. This is why I am in fellowship. There may be some nuance I am missing...


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[inspirationmd]

Also. @jdh...I used to think your statements that critical care was much more than procedures and management of beyond internal medicine was BS. Yeah I was wrong

Man was I wrong. You definitely need fellowship to do this specialty right. The hospitalists out there who think that experience alone can make up for this don't understand.

Looking forward to becoming an intensivist at the end of this.


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[IMreshopeful]

Man, I make one little comment that wasn't entirely serious and look what happens

There are other intangible reasons to use Swans that haven't really been discussed here such as eligibility for IA status on transplant listing for hearts (indicating need for continuous hemodynamic monitoring). Also have seen a couple cases where a RHC picked up a cardiogenic shock when the physical exam and labs just wasn't definitive. I also fully agree that of course Swan ganz catheters don't improve mortality in any studies, but I still have seen instances (used by trained intensivists as well mine you) where it's been helpful.

Anyway hopefully I'll learn more when I start cardiology fellowship.

 

[Instatewaiter]

No. The reason CTAs aren't making waves is because you're over diagnosing sub segmental PEs and anticoagulating people that don't need it. We're helping some while harming others. The reason you don't see a change in swans is because they just give you a pretty output parameter to stare at.

And, they don't change outcomes.

There is no single diagnostic study on a broad population that has, of yet, been shown to change outcomes. Is this going to stop you from ordering CT scans, or CXRs or Echos? Nope

 

[smartparts]

oh look, its this thread again