 So our last speaker, Dr. Jose Diaz Gomez. It's my pleasure to introduce him as the final speaker of the conference. And Dr. Jose Diaz Gomez is a staff cardiac anesthesiologist and intensive care physician at the Baylor College of Medicine in Houston. Dr. Diaz Gomez has trained extensively in both anesthesia and critical care medicine across multiple sites in both Columbia and the United States, including residency at the Cleveland Clinic where he went on to serve as both cardiac thoracic anesthesiologist and intensivist as well as assistant professor of anesthesiology. He has subsequently worked at other prestigious institutions such as the Mayo Clinic in Jacksonville and the Baylor College of Medicine in Houston. He is currently obtaining a master's in applied science in patient safety and health care quality at Johns Hopkins Bloomberg School of Public Health. Dr. Jose Diaz Gomez. Thank you. Can I share my screen? Is that okay, Dr. Perez? Yes, Jose. Yes, you can share your screen. Thank you. I want to thank the committee for this invite and especially my dear colleague and friend, Dr. Paolo Perez-Dampar. I really want to show you what I consider is the highest point of contribution to utilize point of care ultrasoundography in estercorporeal life support. And I take this from one of my favorite books, this graphic where I always making sure whatever I'm doing, there is a reason why I'm doing so. So the way I have put this online, I will tell you what is POCUS, what is ECLS, when we are doing that and why we do it. So there is a disclaimer and everybody knows here that when we are doing ECLS, patient selection will be essential on that. And we have kind of optimized our acting flows and doing band strategies based on echocardiography. I work in a cardiac thoracic ICU every day. So probably that's different when you work in another setting that is not that so specialized. And ultimately, I really care about those longer outcomes, especially as I need to provide some bridge to recovery or actually transplantation to those patients who have such a catastrophic event. So what is the point of care ultrasoundography? I will give you 10 seconds to read the definition that we put together back in 2021. What is that important? Because these definitions empower us that we are not cardiologists or radiologists. That doesn't mean to be divisive at all. And it gives us the opportunity to go and collaborate with those colleagues so those colleagues know what we are using this for. And what really the cardiologists have loved about this definition is that immediate clinical integration. I know that you can plug this definition in whether you're doing critical care echo, whether you're doing an assessment as a hospital. So this will be at the bedside utilization of ultrasoundography in ECLS. Okay. What is the future for Parkers? Well, I have some news for you. We are going into details. The handheld ultrasound system will be more available. There will be less buttons. The images will be faster and will have artificial intelligence. So the future of Parkers is extremely bright. However, we still have some issues and you can see in this paper how the older societies or our colleagues continue complaining that apparently we haven't paid that much attention about training and experience. And that's probably the reason I'm bringing this definition as a very good first step. I'm assuming that everybody who's coming to this course at least have the skills to utilize the tool in the right manner. However, you see here in the right, they are acknowledging that pretty much we, intensively, so critical care specialists are probably the ones who can do better Parkers. And I can take that as a good sign that we have evolved in this collaboration with our cardiology colleagues. And definitively, it's a very good point. It's a very, very specific moment for us in collaboration with cardiologists. Okay. So what is the ECLS? You can see the definition there. And pretty much we try to really do this in selected patients who present cardiac arrest. Right now, my center is close to 200, you know, at most this year. So we have a significant volume and that's the reason I accepted this invite by Dr. President Park. Okay, when we do it, based on the data that is available, chocolate rhythm, and pretty much we are able to do this in less than an hour after starting CPR. It's better if the patient has a higher pH and lower lactic acid. Those are good, good, good things to deploy this. I need to take this paper that is actually coming out of Europe when in Germany, you can see now there are two things here coming to your mind. You're seeing they are doing the providing ECLS. They are doing ECMO. They did this for 254 patients. But guess what? Beside the fluoroscopy, they put ultrasound. And you will remind this in the end of the presentation. Let's go to the why, which is the core of the presentation. Number one, it's good to characterize what is the theory of the cardiac arrest? Number two, we'll try to see where the cannulas are. Three, how we'll start that support, and then we can face some complications. In this case, this courtesy from one of my colleagues at the Powell here, and yeah, we are trying to see how well we are doing the compressions. Okay, and then this is something I have developed over the years that there are protocols that give you with doing the pulse check to see what will be the theology. But in fact, you can do even just leaving your pro in place. You can see how you can probably rule out some of the pathology. So this is important. This one was not running. You can see even during compressions, I have developed that skill. And I'm not saying that in a, in a way different that as you're able to refine how to do this with your teams, I just trying to make a parallel with what you can do with your T or TT. I don't have any distinction. I don't have any bias. I should be capable to do both, both techniques depending on the patient, depending on the situation. I can challenge you in those cases where we have probably a couple of hundreds of years a year. You can put a T probe so it is your responsibility to really become proficient in both techniques. So in this case, for example, we are trying to really characterize diagnosis here and this is so meaningful just to, to see how you are facing now. Okay, you can address these pathology. And in this case, how this patient has have P and it has under-filmed and you have better characterization what you're doing here. You can save it as this patient. And this is a transfer yield view. I can see very typical subtle P. How can you rescue a patient after a cardiac arrest without having this image. In this case, sometimes we got surprised. Look at this was one of my recent cardiac arrest and then the patient had actually a type A dissection. Then we go, we start doing cannulation and of course, the surgeons or the interventional calories or another intensive is can make guidance regarding the position of these wires and this means of ideal view, as you can see that. And then you complement with by cable view and trying to see how to do a wide advancement as you put in the penis canola, then avoid cannulation noise in the body position. And then this is important as well. And you have to really make sure whenever you are so the beans on the figure where they are landing. And I'm showing you here how after a femoral period of cannulation, I can see my wire. Then we start, we now initiate, let's say that the vehicle. And after doing that, we try to see what is the response. And then we started seeing a new finding here, for example, now you, you have, you have a new issue. And it happens and then we are able to diagnose that actually that patient now is having a big, you know, tamponade there. So this is very, very important as an initial complications. Okay, and sometimes we got called to the bedside, and we need to reassess the flows and it's important to see when or what is expected in this case, we have the ability to really use color for Doppler and evaluate the flow. Or sometimes we need to make a call and say, you know what, we probably were trying to decompress this is ventricle but it but it's too much. And then, because of that, we can readjust the management. In this case, for example, and we have this private response in the new, and you have that then you can really readjust your therapy. So it's a real way to personalize management after, you know, ECLS. Then sometimes we are in a very bad shape. And then when you have this kind of minimal flows. And this is a really bad complication and able to have a better discussion with our surgeons and determine futility. So I, you can see the wide spectrum of what these kind of imaging brings to table. Of course, it's not only for VA ECMO, primarily, that was the main indication. But sometimes we would need to put a balloon pump and some of our surgeons believe there's a good way to combine with VA ECMO or even right now we are really trying to determine the best way to do so. But once again, you can see the application when utilizing enter out the balloon pump in patients with VA ECMO and using three dimension eco-friendly to ensure that it's in the right position. So, this has been a really explosion over the last two years in our institution and the utilization of impella supports going really, really high. And for any new hypertension, any alarms, they know that definitely will do eco-friendly assessment. So once again, this standstill image here allows you basically to have the measurement and thus direct communication. And we have even the capability to, you know, communicate with our interventional calories that are not here, they're at home. And this is the way you can really excel in that regard. So, but why then does has the role. I have show you what, when and partially the why. But there are three questions that should come to your mind right now. Number one is that, can I provide safer care when I'm calculating vessels, especially in these emergency situations? How can I make sure I tell whoever is doing it or even myself that the calculation was appropriate? How can I make it faster? You cannot spend half an hour just can already in a picture. Okay, is it easy or less? So, there are the evidence is as follows. And improving the cannulation time, just being partners and the cannulation time. You can see here how when you do with partners, 20 minutes, poroscopy, 15 minutes, and Lamar, 22 minutes. So, okay, is that the real answer? And that's to be focused in the time. However, however, when you're seeing the misplacement of cannabis, then we can't follow them because you can see here, meeting the partners or in the poroscopy group, there were any misplacements in the camera. But here you have three, and I will tell you so only three Jose. Let me ask you this, what is that? Any of those three patients are even a friend of yours. We should really maximize patient safety in 2023. We have the tools which need to be better organized and apply these tools better. And that's the central message regarding this application. So, it appears, and again, even not in my own institution, and I will be happy to take that question and interact with my colleagues from Toronto. But the vast majority of institutions in the world cannot achieve the combination of both modalities. So, my dream is to have both ultrasonography and poroscopy. And I know there are some advancements regarding having more portable poroscopy units. But to me, to do this at the point of care, we really need both. We need both. And any intensities should be incapacitated to manage linear probe, to trans-terrace it, to transesophageal, and do poroscopy if they really want the safest care for these patients. So, you can see in this study, when they were using poroscopy-guided cannulation and ultrasound-guided cannulation, you can see here the complications. Okay? The complications. Wow. There was a difference there. And you can see when, in my institution, at interventional categories during the NCLS, most of the time they try to put a patient in the cath lab or what if the patient is crashing in the ICU? We try to bring the poroscopy. But for the most part, I'm the one providing basically ultrasound guidance, including PE. So, what we have, so what we have is the following, is that ultrasound guidance, you start with your linear probe, and then after that transesophageal, and then we try to really make sure that we don't have issues with the limbs. And that's probably the very first really early complication that triggers a lot of back problems. And then we have to take a look for 10 seconds, this KUB. This is a previous case that I have. And why do we pay attention to this case? Only afterwards, only when we're doing winning of the ECMO. We discovered that the patient was not a VA ECMO. And it was a cardiac arrest. We have venous-venous because these arterial cannula went from the artery was crossed and then pierced the vein again. So actually this patient was on venous-venous the whole time. So, this happens. So, once again, this case has made me so humble that we really need to be the best efforts to provide poroscopy and echocardiography. Cardiac arrest, minor number 10. I have very clear the patient selection. I should have in mind poroscopy and my point of kerotationography. And then basically this is the goal to provide VA ECMO. We can try to see how energy we need to go to the cath lab because we need to rep refuse. And then here, we know what to do with echocardiography, optimizing the ECMO flows, and then making sure that it involves, it involves this opening, preventing every extension, and even considering preventing morality. That's what we do. Lastly, now we're going to share with you a case that happens to me earlier this year. This is a 44-year-old patient. He had a lung transplant. She arrested. I took over. It was the evening. Wow. I'll say this patient has, you know, their low-flow alarms. I don't think this is, these are the legs, basically. And she has access, you know, both, both groins. I'm like, wow, okay. So, I was trying to see what was going on. This was, if you can see, I'm not going to say the brand, but this is a handheld transom system. No, not a big, it's a portable one. Again, this is my personal one. That's the way I do it here. So, I'm not thinking that, okay, well, you know, I can see that this is working somehow. I have the color flow dropper. I'm probably suspecting that, well, the volume wise is low, and it's starting to see here some fluids. So, I continue doing it just because I was there. This was a porno vein assessment, which is more consistent probably with volume started being on the lower side, and I continue doing my point of care rotation of it. Now, I'm seeing actually free fluid in the abdomen. And I didn't like it. I really didn't like it. So, I continue scanning and then it's free fluid in the abdomen. And the patient has cardiac arrest, and then they put a VA act on what I go from here. So, okay, so basically I call a vascular surgeon, and I say listen, I call a acute care surgery. I say, listen, I have this situation where there's fluid that it might be, it might be blood. Can you help me out? So, okay, sure, Jose. So, I completed that with this is the assessment of the heart. You can see, you know, the audit box is open and nothing like out of proportion, and then you can see then the thoracic vein. And you can see the part of this patient was almost 310 pounds. So, here we have the apical view. Okay, I brought them. So, basically, I did a synthesis of telling them, okay, if blood is coming out and it's not temporary anymore, you have to help. So, now I have, you can see here, 1.5 liters of blood. I put a pigtail. Okay, we went to the OR. You can see here the ECMO, all this blood coming out. Now you have open abdomen that removed like my brain. You know what happened? With the CPR, there was abrasions of the capsule of the liver, and that was causing the hemoperitoneal. It's the first time I'm facing that in my life. Once again, it's handling, but I wouldn't have the hand held to some system to have another complication. I wouldn't be able to catch that. And only the first time was low flows in the ECMO because they increase interdominal pressure. When I was able to drain that 1.5 liters, the patient gain flows right away with the ECMO. So, in conclusion, the highest point of Parkus contribution in CLS is achieved when we are able to recognize what ECLS is and we apply it alongside Parkus at the right time that the candidacy. And Parkus seems to facilitate safer, more reliable, and timely cannulation in CLS, especially when it's combined with fluoroscopy. With that, I want to thank you here from Houston. I don't call today, but it has been a pleasure joining this prestigious panel. You have put together. Thank you. That is the part for you to invite again. Okay, thank you so much. So, I have the honor now of opening up the Q&A session. So, unfortunately, a few of our presenters, including Dr. Wiskar, Dr. Nicol Van and Dr. Toran are unavailable to answer questions just due to unforeseen circumstances. So, luckily, we have Pablo here and Jose, but Dr. Dano has also agreed to help answer some questions, especially regarding Vexus with which he is familiar. So, just going to the Q&A to start, we have some questions. So, Julian asks, what is the physiological explanation of hepatic S reversal without any TR on the Vexus score? And Dr. Dano, would you be able to provide some insights into this? Yes, for sure. So the question regarding why S is reversed when you have tricuspid regurgitation, is that it? No, I think it's in the patient without tricuspid regurgitation. Why does that happen? So what happened is that the S wave is really during systole. So, typically, what will happen during systole is normally you have the motion of your tricuspid annulus that's squeezed toward the apex. And that creates the systolic flow from the hepatic vein to the right atrium. So when you have RV dysfunction, even without any tricuspid regurgitation, what will happen is that there's going to be no motion of the tricuspid annulus. But then during systole, what can happen is that the tricuspid valve might bump this way. And this motion will create the reversal of the S wave that you can see in the hepatic vein, even if you don't have any tricuspid regurgitation. In addition, what you'll see also in your CVP waveform will be a big V wave also. That's the other element that will be complementary with this element. So actually, Dr. Nero, I just have a question regarding the use of exis in an ICU population. A lot of the studies that were discussed talked about using it longitudinally during an ICU stay starting from postoperative day one or immediately after the operation. So can you use it longitudinally before and after extubation or before and after the initiation or the discontinuation of positive pressure ventilation, and then in an extubated spontaneous ventilating patient, would you be able to correlate the before and afters or not really? That's a good question. The studies that we did that were mostly by William Bobien Sudini, who was a nephrologist who presented yesterday, the way we did it, we just did one measurement, you know, every day for three to four days. And that's really how we got our experience. And I would typically do it, you know, more in a more longitudinal fashion than necessarily acutely. Because if ever, and you can, you can, you can look at this, if ever you take a patient, for instance, and you give him a fluid ball is very, very fast. Okay, you'll see instantaneously a portal possibility. And we see this even when you give it to normal people because you're what's happening is that you're raising suddenly the right to pressure. And all the vexus issue is basically transmission of the right to pressure in the periphery, which should not be transmitted in the periphery. So anything which will increase suddenly your right to pressure will increase the possibility. We just completed a study in which we look at an element which eventually might come into the vexus core, which is the femoral venous Doppler. And the femoral venous Doppler should be continuous, like the portal vein. So what we found is that if you do it just before and after the intubation. Okay, so what we found is that at baseline about 20% of patient of possibility, you know, before cardiac surgery, but after intubation that goes up to 50%. Okay, and that's probably because you're increasing the right to pressure with positive pressure ventilation. On the other hand, what we observe, and that's why every patient is different, is that we had a certain number of patients in which the possibility was present before the intubation, and resolved after the intubation. Those were patient with mitral regurgitation, aortic regurgitation. And you know that with induction of anesthesia, you create vasodilatation. So the benefit of the vasodilatation in those patients was greater than the effect of positive ventilation on the right heart. And that's why in those patients, we saw normalization. So these values can change rapidly. And then the significance of these rapid change, I'm not sure the meaning of this, but when the signals is constant and when you see it changing over the days. And in fact, what we observe is the peak change after cardiac surgery was on the second day. And it's often on the second day when you mobilize your fluid, you go in pulmonary edema, your creatinine goes up, your lactic goes up. And that's really on the second day that we observe this. And this is really when you're really, if you see this, that's really when you don't get fluid. You know, we remove fluid in those patients. So that's been a kind of our experience with the Vexus Core in our institution. Thank you. Thank you so much. So, Pablo, I'm going to ask you to comment on lung ultrasound. I know you perform quite a few, you know, poker studies being such kind of efficient out of yourself. And the question that comes regarding lung ultrasound is can you comment on adding color Doppler on lung with consolidation for optimizing the diagnosis of pneumonia. So, for the diagnosis of pneumonia, one of the things you want to look for in lung ultrasound is the dynamic bronchogram that Sarah showed a couple of slides where you feel like bubbles popping up, where you can, if you will, add colors to it, you could also see that changes in different directions of the flow. But to my knowledge, it doesn't really offer an active advantage in terms of diagnosis for pneumonia itself. Yeah, I agree with that. I don't tend to use the color Doppler in order to add any kind of diagnostic utility. Dr. Danone, do you have any, any insights? Well, I have one of my colleagues who was doing a study looking at pneumonia and looking at Doppler tissue Doppler in the in the vessels is hypothesis is that when you have a severe pneumonia you're going to have a shunt. Okay. And but if you have a consolidation where you don't have so much epoxy that means that you have visual constriction, you know, epoxy visual constriction. So his hypothesis was that maybe the velocity would be different. You know, if you have a true consolidation with pneumonia in which you would have a shunt versus a consolidation in which you have preserved epoxy visual constriction. So, but I think he's still under the recruitment phase so I cannot tell you more but the idea is also based on this on this concept. People also in pulmonary embolism and in peripheral pulmonary embolism people also use color Doppler to see there's no flow in that in that region but I personally don't have much experience using color Doppler in those situations. And Dr. Jose Diaz Gomez, do you have any insights or any additional considerations I know you're advocating or trumpeting the utility in the need to be able to be very comfortable and fass out with both point of care ultrasound using handheld modalities as well as TE floscopy these different modalities. Do you use color Doppler specifically when when helping increase the diagnostic sensitivity. Let me let me take one step back and I think something I really need to advocate for is that do not forget your primary role as a clinician. I will tell you I'm not aware of anyone. This is continuing antibiotics or not giving empirical antibiotics on somebody who has a clinical suspicion based on the ultrasound imaging, or I'm trying to say is that the value of using color flow code or power Doppler. I don't think you have enough evidence to say that would really should influence your clinical decision making. If a patient has clinical suspicion of pneumonia, you should treat it and it's the same in parallel, if you will have a CT scan or you have a chest radiograph but I will be opposed to try to put an ultrasound modality over the clinical picture, especially with the patient population I deal with that are transplant patients you know I'm going to suppress patient I cannot apply that and I've been always challenged by very reputable cardiologists or pulmonologists. Jose, are you taking the decision on image. So we're not an image in a specialist. We're primarily clinicians using a powerful tool that have diagnostic capability. So another question regarding Vexis. Dr don't know I'll direct this towards you. And do you see any additional value of doing renal Doppler on top of portal vane Doppler interrogation Vexis. That's a good question. The portal then is much easier to get you know the success rate you know experiences more than 95 90 98%. In fact, the situation where you don't get it. It's often very obese patient where you have a very steatosis very bright liver. And in those patients what you can do is can you can just look at the spleen and look at the spleenic vessels which will give you also the same similar information. In the, if you have significant portal possibility. It's rare that the kidney will be completely normal unless it's a false positive. Okay, and this can also this is also part of the limitations. But I think the whole idea is when you look at the Venus system is try to have as much as possible evidence that there's general Venus congestion everywhere and if you have a good signal on the kidney. I think that's additional evidence that this kidney is congested and definitively will not improve with more fluid. So that's, I would say, that's the advantage it supports your finding. And the idea of the vector score which was developed at the heart Institute by Dr. Surini originally validated is to try to, to take more than one elements and if you take more than one elements the probability of a response or the association with with the outcome was much better than if you just take one on his own. So, I think, I think it's a it's a good, it's good habit to, to have a quick look and to see those, all those elements put them together and take a decision. And I agree with Dr. Diaz Gomez. Don't treat a patient, you know, don't treat it and also son image we treat patients. And we try to put this together. And also when you do the vexus where I'm lucky I do cardiac anesthesia all the time and I can correlate it with the CVP waveform with the right denticular way form also so I know that it's it's all related to RV dysfunction and and then you can take the better decision regarding how you manage the patient particularly in terms of fluid management. I think what we all kind of advocate for is the use of ultrasound as another point of data for triangulation as opposed to, you know, so reliance and I think the more familiar and the more comfortable you are integrating these various imaging modalities or diagnostic modalities to probably closer come to the truth in all of these various diagnostic dilemmas that we come up with. I'm going to ask you because I know you're very experienced and you lecture a lot on use of transesophageal echo during resuscitation acute CPR and rest situations. And do you think there's any concern for esophageal perforation when you have a transesophageal echo in during active CPR. That's a great question. Sorry, just a doctor trying to connect but he's Wi-Fi is not helping so I'll I'll I'll answer. Yeah, that's a great question. To my knowledge, although it seems like a very honest concern. No increase in incidents of major complication from T during chest compressions and and the complication quoted in the literature, which at this point is still there's quite a positive of the literature and in the in the terms of cardiac arrest and use of T, it hasn't been shown any increased risk of performing T during during chest compressions so far. But it's clearly a potential concern. You just need to keep in mind the usual. We'll have an any other patient having a T and the relative and absolute contraindications and the same in terms of performing an adequate technique for probe insertion to avoid any any any further trauma or injury so far. Most of the injuries or complications have been reported as being due to insertion, most in the orference and the or cavity. So let me ask you, like Pablo in a hospital kind of wide and spread out a sunny book is what are the logistics or some of the practicalities of, you know, getting the arrest call being able to mobilize a team with the T getting the machine and the probe to the ward where the rest is occurring finding out enough information in order to recognize whether it's safe or not to proceed with tea and then actually performing the study in in a way that's clinically useful. How does that unfold like what are the logistics of that at at the hospital where you are because I know you're able to do it with some success there. Yeah, so this is also a great question. So we're lucky enough that in our emergency department, there's a very strong point of Carol Georgetown team and program. In fact, Dave, they're the one to perform the interest. If there's a cardiac arrest in the emergency department, they have the capability in terms of equipment and personal to perform the reciprocity and get the information from that. In the operating room, since obviously we're a cardiac center, there's always cardiac within normal hours. But other than that, we have been training and we have trained now a few small group of non cardiac anesthesiologists, then at least being able to obtain the resuscitated four or five years in the context of a cardiac arrest. And in fact, not only using the full cardiac or the machines, but a couple of our focus machines like the portable ones. They also have the pros that can be used for and we can save those images and the same applies for the ICU a couple of years ago. So we started training a couple of our intensivists, like a non anesthesiologist intensivist and also resuscitated. Logistically, they also have the machine and the capabilities of doing the study in the ICU. Out of the ICU, out of the war and emergencies, it's not, it's not feasible, not possible so far. So maybe we'll get there at some point, but the idea to like build that collaboration between those three departments, the ICU, the emergency department and the NDOR to have the capabilities of first help each other, collaborate to each other. And now, in fact, we share the archive system, we share it among the three departments. So we can all upload our scans, studies that we can all share and look at each other's studies and work as a QA process in terms of that. So you feel as most of the utility is in the emergency department in the ICU as opposed to general medicine. And in the operating room. Yes. Yes. So far, yes. Yes. Like, I don't think we'll get to the point like even doing a trans thoracic in the ward is still, still not easy. Okay, because unless it's mostly because of training, unless you have somebody who's always available to perform a quick point of their ultrasound in the context of a cardiac arrest. And it's just challenging to have it at every single cardiac arrest that happens in the hospital outside of the period of their various or the ICU or the emergency department. Fantastic. Okay, so that's all of our questions and that brings our Q&A to close. Thank you for all your involvement and Dr. Dono for adding his expertise last minute. So thank you very much, everyone for your participation and your attention over the course of the weekend. And now I'll hand over to Annette for awards and closing remarks.