Ashley Miller
@icmteaching
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Following
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#zentensivist #FUSIC co-chair. ICS council member. Former BSE committee member & examiner. BJJ ⬛️⬛️🟥⬛️🥋. No politics, no pets, just #foamed #fluids #pocus
United Kingdom
Joined December 2015
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Fluids or vasopressors or inotropes & why?
CO = HR x SV but altering cardiac contractility or HR (by themselves) won't normally change CO🤯
Here's a 20 minute talk using infographics to try and simplify concepts that often seem very complicated.
#FOAMed
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How vasopressors increase stressed volume to increase venous return. It's all about the veins!
#IFAD2020
@Fluid_Academy
@Wilkinsonjonny
@FOAMecmo
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Part 2 of my 'rational fluid prescribing' series 💦
'The micro-circulation'
⭐️Why sepsis doesn't cause hypovolaemia
⭐️The
#glycocalyx
⭐️Extended Starling principle
⭐️Albumin
⭐️Capillary leak
⭐️Where IV fluid actually goes
...and more
#FOAMed
👇
#Vimeo
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500 of these just arrived from the printers to help my mission of safer fluid prescribing
@sathNHS
£20 well spent when Fife saved 100k/year. Lots more measures to come to improve IV fluid safety.
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Blood gas challenge. Who can explain this? PS I found it hysterical that the glucose was circled 😂😂😂. Note U.K. units
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We’ve seen how to measure VTI and stroke volume with
#ultrasound
Our next
#FUSIC
haemodynamic question brought to you by
@icultrasonica
,
@wilkinsonjonny
and I is:
Q2. Does SV respond to fluid, vasopressors or inotropes?
#echofirst
#POCUS
#haemodynamics
#foamed
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6 years in the making. Never again but delighted to get it over the line. Well done to chief editor
@AndrewW21023349
and my fellow editors. Thanks to all the authors.
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#IFAD2021
Updated after rightly pointed out to me that the bleeding box could have been better
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Just got my copy through the post. A really excellent textbook on
#POCUS
. Honoured to have contributed. Available from Amazon. DM for discount code.
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Want to help fluid prescribing in your Trust? Try printing credit card sized guides to tuck behind an ID badge. Example here from
@sathNHS
For more ideas register for this free webinar:
⬇️
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When it comes to haemodynamics, ultrasound can answer the critical questions that need answering at the patient’s bedside.
@ICUltrasonica
, the rest of the
#FUSIC
team and I are proud to present FUSIC HD.
We hope it will greatly benefit patient care.
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Post holiday season,
@ICUltrasonica
,
@wilkinsonjonny
& I are back to take you through the most most critical clinical questions on
#haemodynamics
that ultrasound can answer
We’re now on to question 3 of FUSIC HD
’Is the aorta abnormal?’
#FUSIC
#echofirst
#POCUS
#FOAMus
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It's impossible to teach everyone
@sathNHS
about IV fluids so going to put it all on youtube. Think a video lecture series will be better than 1 massive lecture. This is going to take a while but will be well worth it in the end.
@SaTHImprovement
@Fluid_Academy
#patientsafety
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The lung bases are the trickiest part of lung ultrasound. Here's 90 seconds on how to get those rib shadows out of the way and still maintain orientation.
#POCUS
#FOAMed
#FOAMcc
#FOAMus
#echofirst
#vscanrocks
#GEVenuefamily
@Wilkinsonjonny
@ICUltrasonica
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Can we distinguish between hypovolaemia and vasodilatation with echo? This concept highlighted by
@IM_Crit_
is one that gets repeated in articles and textbooks. But is it true? This is a really interesting question that requires a 🧵
Ok, I just found where I read that the LV end-diastolic dimensions can help diffentiate hypovolemia from vasoplegia. It was in one of the ASE guidelines papers a few years ago. Time flies!
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Lung protective ventilation, setting PEEP, driving pressure, ventilator modes, weaning, asthma, obesity....
@Wilkinsonjonny
and I present this quick guide here:
Interested in expert feedback to make it even better too! (Calling
@charlot_summers
)
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ICU
#haemodynamics
1. Thoroughly enjoyable haemodynamics teaching session online last night with
@katiewiskar
@heart_lung
@khaycock2
@ThinkingCC
@chatterJ5
Made me dig out an old case to illustrate the most common shock scenario we encounter on ICU...
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What hand-held ultrasound device is best? I recently got my hands on the new
@vscan
and
@Wilkinsonjonny
@ICUltrasonica
and I have been putting it through its paces. Our full review will be coming soon but here I'll show you some comparison pics with
@PhilipsLumify
(gold standard)
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My 10 minute talk mythbusting capillary leak for
#SOA21
.
#FOAMed
⭐️The
#glycocalyx
⭐️
#Oedema
⭐️
#Fluid
resuscitation
⭐️
#Albumin
⭐️
#vasopressors
@iceman_ex
@Wilkinsonjonny
@FOAMecmo
@Fluid_Academy
@emcrit
@PulmCrit
@CriticalCareNow
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To know you are looking at the optic nerve and sheath you need to identify:
1. optic disc
2. retinal vessels with colour doppler
3. hypoechoic nerve
4. hyperechoic sheath
5. shadow on either side of the nerve sheath (which should not be included in any measurement)
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This is a short version of 1 of a series of talks I'm releasing on rational fluid prescribing. I'm always trying to make the complex physiology simple and useful in terms of informing practice. I'd love to hear your feedback
#turningthetide
@Wilkinsonjonny
@PARADicmSHIFT
Watch the latest Education Shot video: Macro-circulation physiology, by Dr Ashley Miller.
📺 Available now:
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Hypernatraemia is an independent predictor of mortality.
It is common, but completely avoidable, in hospital.
See this 1 page guide for diagnosis and management.
#FOAMed
#hypernatraemia
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Congratulations to
@GHOSTSnowflake
on passing his
#FUSIC
lung ultrasound triggered assessment today. Our 1st ACCP to become accredited in lung US. Hopefully will be closely followed by our brilliant physio
@clarabellagood
@ICS_updates
@sathNHS
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Want to learn TOE but always thought accreditation was out of reach? No longer.
@ICS_updates
and
@Assoc_Anaes
have collaborated to bring focussed TOE within reach of all acute care practitioners.
Start your journey now:
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Aortic dissection is easily missed, carries a high mortality and should be on the differential of any patient with shock, abdo pain or chest pain. Contrary to popular belief the entire aorta can be imaged via transthoracic and abdominal ultrasound. Let’s start with some anatomy
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If I could only use 1 thing to guide fluid management in ICU it wouldn’t be
#echo
, other ultrasound, any other kind of cardiac output monitor, CVP, urine output, blood tests etc. It would be my index finger poking the patient in the hip (most dependent area) to look for oedema.
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From Guyton to the Glycocalyx. How physiology informs fluid prescribing.
Why:
Sepsis does not cause hypovolaemia.
95% of a fluid bolus can stay in the vessels or leave them.
Oedema is not benign.
What is:
Venous congestion?
Capillary leak all about?
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#SOA21
is here! While you're waiting for it to start why not check out the soap box on demand? You can see my talk in tomorrows main session or watch it now.
Capillary leak - misunderstood
Glycocalyx - what does it do?
Rational fluids
Albumin - a waste of time
@ICS_updates
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Fluids - what's the harm? via
@YouTube
@Turningthe_Tide
@ICUbreeno
@MarciaMcDougall
@Wilkinsonjonny
@PARADicmSHIFT
@anaestheticdoc
@ICUltrasonica
@thomaswoodcock
@BukuRenal
@Fluid_Academy
@FOAMecmo
@msiuba
@khaycock2
@ThinkingCC
@load_dependent
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Son injured his wrist playing touch rugby yesterday. Just a sprain I say (no bony tenderness). This morning tender distal radius. Get out the
@PhilipsPOCUS
lumify ultrasound and see this. Now awaiting XR 😜
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Digging through the vault and found these lovely air bronchograms. The surrounding lung is so consolidated you can 'see' the air in the bronchial tree. There's an effusion too.
#POCUS
#lungultrasound
#FOAMed
@Wilkinsonjonny
@ICUltrasonica
@GEHealthcare
@jrobi09
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Degrees of aeration with lung ultrasound. Fully aerated to fully consolidated
#FUSIC
Only about 100x better than a CXR....
@Wilkinsonjonny
@ICUltrasonica
@PARADicmSHIFT
@iceman_ex
@NephroP
@kyliebaker888
@ICS_updates
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New guideline on fluid management of patients in critical care
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A lot of excellent answers. This was a patient with days of severe vomiting. Metabolic alkalosis from chloride loss. High lactate from hypovolaemic shock (with high Hb). -13 towards an acidosis but +24 towards and alkalosis (135-73-38) so alkalosis wins. (38 is normal NaCl gap).
Blood gas challenge. Who can explain this? PS I found it hysterical that the glucose was circled 😂😂😂. Note U.K. units
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Patient on noradrenaline (norepineprine) had it reduced. Explain the changes in the observed numbers on the cardiac output monitor:
MAP 70➡️52
SV 84➡️73
SVV (SV variation) 3➡️8
SVRindexed 1190➡️870
#haemodynamics
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1. Lichtenstein described a 12 zone protocol for LUS in 2004. By 2008 he had demonstrated with the BLUE protocol that a 6 zone scan was as accurate. A study in 2011
again confirmed 6 zones were as good as 12...
Lung
#ultrasound
in
#COVID19
: less (zones) is more??
➡️12 vs 6-zone protocol
➡️each zone scored 0 (A-pattern) to 3 (consolidation)
➡️LUSI calculated for both
Monitoring > 6 zones does not appear to provide additional information.
#POCUS
#echofirst
#FOAMus
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1 in 5 patients come to harm from fluid mismanagement I'm going to be talking about this @
#SOA22
.
@ICUbreeno
&
@MarciaMcDougall
will be telling you how you can fix this in your hospitals. Come join us next Friday in Belfast or online.
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Join
@Wilkinsonjonny
@PARADicmSHIFT
and I to find out all about IV fluid management.
Part of
@ICS_updates
free webinar series.
Physiology, evidence and practical advice
📅Feb 4th
⏰20:00
Register here
👇👇👇
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Want to know pitfalls 🚨 and pearls 🦪of optic nerve ultrasound for⬆️ICP? Find out why it is often done wrong (even in studies) and how you should actually be doing it
@Wilkinsonjonny
@ICUltrasonica
@iceman_ex
@ManniWaraich
@kerlijnevdb
@lauraellen115
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Intensive Care ultrasound fellowship
@SaTHjobs
with me. 50% on call. All other time for ultrasound. Starting August. You can be a novice in US or a ninja looking to hone your skills. 6-12 months available.
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Please spread the word. New ICM ultrasound fellowship with me!
@Wilkinsonjonny
@PARADicmSHIFT
@iceman_ex
@JagtarPooni
@ICUltrasonica
@ICS_updates
@aroradrn
@CUSICUK
@HocusPocusUK
@bhca
@LouiseSykes20
@avkwong
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Online e-learning now available from
@ICS_updates
for
#FUSIC
ultrasound. All the course lectures for heart, lung, abdomen, DVT and vascular access delivered by our dedicated committee members. Register and learn from the comfort of your own home
#echofirst
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I'm looking forward to talking about fluid management and ultrasound next week in Valencia. 🇪🇸♥️
Tengo muchas ganas de hablar sobre gestión de líquidos y ecografía la próxima semana en Valencia.
#44SEMI
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Updated ventilation guide. PRVC clarified, asthma improved, dyssynchrony links added and transpulmonary pressure equation corrected!
@Wilkinsonjonny
@cianmcdermott
@msiuba
3
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Standing room only for my talk on fluids and ultrasound. Pressure is on!
@yaletung
@Sociedad_SEMI
#44SEMI
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Haemodynamics work best at euvolaemia. Organs function best at euvolaemia.
#turningthetide
@PARADicmSHIFT
@Wilkinsonjonny
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Brain ultrasound is not just for neuro intensivists. In a DGH you can use it to answer these questions:
Is there evidence of raised ICP?
Is there midline shift?
Is there evidence of vasospasm?
Is there evidence of impending brainstem death?
Expand your🧠
🧠 We have a new
#FUSIC
webinar for you tomorrow evening on an 'Introduction to Neuro Ultrasound'
💬Join the conversation with
@iceman_ex
@ManniWaraich
&
@icmteaching
🕖 On 29 October 2020 from 7-8pm
👉
#NeuroPOCUS
#FOAMEd
#ICM
#Neuro
#Ultrasound
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#FUSIC
heart and lung ultrasound course underway
@sathNHS
with
@Wilkinsonjonny
@easypocus
@parulekar8550
superb customer service as ever from
@8geo8
providing all the GE machines. New
@SmarterScanning
heartworks simulator in use too.
@ICS_updates
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Organ perfusion is highly dependent on venous pressures. These are easily assessed with ultrasound. Here are some powerful case histories.
#FUSIC
HD
Thanks to the authors
@ThinkingCC
@curromir
@ArgaizR
@khaycock2
et al 👏👏
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17
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This is the best review of R heart echo I have yet read. It will be in the essential
#FUSIC
HD reading list. Congratulations to the authors.
@MaxHockstein
@khaycock2
@msiuba
et al
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Look what’s just arrived! Can’t wait to set this beauty up and see what it can deliver
@8geo8
@jrobi09
@lauraellen115
@kerlijnevdb
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🚨Calling all
#PoCUS
enthusiasts 🚨
Opportunity to present at the UK's largest critical care conference
@ICS_updates
2021
Competition for top 3 prizes 🥇🥈🥉
Expecting some brilliant cases where management changed & lives saved
Any organ system
🧠🫁🫀🤰
Details in thread
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Does the heart🫀pump blood around the whole circulation 🔃 or is VR driven by elastic recoil? Which camp are you in? Why? And does it matter? Does labelling variables as dependent or independent affect how we treat patients?
Polite debate only please 🙏
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Separation between echo and US is historical as they were traditionally done by cardiology and radiology. In ICU we integrate US with our clinical assessment to diagnose and guide treatment. This may involve any organ system and it should be used, taught and understood as such.
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@MarciaMcDougall
talking at
#IFAD2020
about fluid stewardship having done great work in Fife. Try printing out double sided credit card sized guides like these that people can put behind their ID badges.
@Wilkinsonjonny
@Fluid_Academy
@FOAMecmo
@iceman_ex
@avkwong
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27
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Heading back from the best conference I’ve been to after the kind invite from
@ThinkingCC
. Met some fantastic people I hope to keep in touch with and see again. What a faculty! Cutting edge physiology, jiu jitsu and poutine 💪🏻
@HandRConference
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I'm going to be exploring how we can rationally resuscitate our patients at
#ACCS2023
. I'll be debunking some myths about things like fluid responsiveness, how the circulation is controlled, whether we should be targeting pressure or flow and much more!
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11
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Really looking forward to unveiling the future of ultrasound training in UK Intensive care
@ICS_updates
#ICSSOA
#FUSIC
with
@ICUltrasonica
. It's going to be a great conference
@stevemathieu75
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Chance to present your most interesting ultrasound case at the UK's largest critical care conference. Open to anyone on the planet 🌎🌍🌏
#POCUS
#echofirst
#ultrasound
#FUSIC
See link and thread for details
👇
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You want to optimise organ perfusion? Arterioles auto-regulate organ blood flow above a minimum pressure. So blood flow is determined by organ compartment pressure and venous pressures. Both are increased with XS fluid administration. Listen to
@ThinkingCC
at
#IFAD2020
today
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@NephroP
When I was 1st learning US I thought everybody on ICU had acalculous cholecystitis until I realised it was just iatrogenic fluid overload. 😂
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Just a few places left on our
#FUSIC
HD course. If you are competent at basic echo go to the next level by learning to assess the whole haemodynamic system.
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Lung ultrasound review in COVID.
#FUSIC
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Great service
@sathNHS
PRH this morning. In and out in an hour and a half to diagnose and cast a #. Kind, efficient, knowledgeable staff throughout the whole process (ED, XR, plaster room). 👏🏻👏🏻👏🏻
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Advanced haemodynamics with ultrasound
FUSIC HD course
Shrewsbury
Tuesday 6th June
Expert faculty
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What a fantastic time talking about ultrasound and haemodynamics in India!
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Been banging on about this for years now. There’s no physiological rationale for fluid (beyond daily requirements) in pancreatitis and lots of reasons for harm.
#TurningTheTide
Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis | NEJM
2
10
41
Looking forward to delivering this talk at
#ACCS2022
later this week and finally seeing people in person!
@CC_Symposium
@veerappan91050
@Wilkinsonjonny
1
15
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Check out my 1 page guide on the diagnosis and management of hyponatraemia
@Wilkinsonjonny
@cianmcdermott
2
10
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Next week at
#ACCS2023
I'm going to be arguing that brain ultrasound for Intensivists is a waste of time....
...against one of the world's foremost experts in brain ultrasound
@aartisarwal
Wish me luck
@veerappan91050
😆
10
7
39
Big announcement from ICS
@ICS_updates
. FICE and CUSIC are fusing to form a single training and accreditation pathway for all aspects of Intensive Care ultrasound. Modular and multi organ. Launching at SOA 2019.
@ICUltrasonica
@Ganesh_ICM
@stevemathieu75
1
19
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Whilst
#ultrasound
is brilliant for patients I've even found it useful for submission grappling
#BJJ
. Knowing the anatomy of the IVC and seeing its collapsibility with probe pressure means I know where to precisely place every 1 of my 75kg to get a tap from side control pressure.
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Year long fellowship available with me in Shrewsbury in ICU Ultrasound. Must be airway competent, ST3+ with UK experience.
⭐️50% on-call (ST3+ level). All other time supernumerary ⭐️
@Wilkinsonjonny
@iceman_ex
@ICS_updates
@ICUltrasonica
@PARADicmSHIFT
2
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@elinlowri
ICU has been saved from being overwhelmed
@sathNHS
by
@elinlowri
and the rest of the fantastic respiratory team.
@fionajutsum
@tivaisgreener
and I salute you!
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If you want to learn about critical care you should subscribe to Matt’s YouTube channel. Here’s one of his excellent talks. 👏🏻
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The results of this trial are unsurprising if you know your physiology. I explain it here in this video 📽️I made for
@Assoc_Anaes
⭐️⭐️
#CCR22
@CritCareReviews
#PREPARE11
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Very easy to have a high ECF volume and be fluid responsive. You have to be MASSIVELY fluid overloaded (in absence of heart failure) to be fluid non-responsive. The safety of fluid removal in such patients can be quite easily demonstrated by filtration while monitoring BP and SV.
Criteria to customize the fluid strategy at different steps of septic shock:
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#SOA22
in Belfast is nearly upon us! Looking forward to learning more about
#ICM
, seeing old friends and delivering a couple of talks.
@ICS_updates
@Wilkinsonjonny
@ICUltrasonica
@Ganesh_ICM
@stephen_t_webb
@sanmather
@thomaswoodcock
3
14
37
Here's a sneak preview of my talk for
#WINFOCUS22
Also a chance to try out keynotes new live video!
Still time to register at
@WINFOCUS
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12
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Critical care trainees in the US report a lack of a curriculum and trainers as the main barriers to training in ultrasound. In the U.K. we have had a curriculum for years. Numbers of trainers are growing rapidly
#FUSIC
@ICS_updates
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check out
@thomaswoodcock
and for more info. I just make his stuff understandable for mere mortals like me
2
6
35
Early Christmas present from
@SmarterScanning
. Am childishly excited about opening these. Enabling us
@sathNHS
to provide world class ultrasound education to benefit our patients
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