Juan Carlos Leoni Moreno, M.D., a cardiologist specializing in cardiomyopathy, heart failure and transplantation at Mayo Clinic in Florida, presents in the Advanced Heart Failure Grand Rounds series on hemodynamic assessment of heart failure.
a more challenging situation. But also it portends were prognosis sodium. Again, the lower the study, um the worse the prognosis is come from the escape trial, also from last decade. And uh I will say that all of our patients actually have that we see here in the clinic are have hyponatremia. To the point that I'll tell the nurses don't even call me. If the study is less than, you know, it's 120 or unless it's less than 1 15, then let me know. But don't call me at four in the morning when the labs get drawn to let me know that the sodium is 1 26. That's actually a part of chronic heart failure. But again, lowers audience will pretend poor prognosis sand with low blood pressure in the lower your blood pressure is the increased hospital mortality. And I will say that most of our patients that we see here, They're runnin. Systolic's between 80 to 100. Actually, if you will see a patient with higher systolic like 1 24 1 thirties, uh and they have a non low ejection fraction ef of 10 20%. It actually, for us it means that they have an issue with after load and that's why they have poor forward flow. So we'll actually start adding after reducing agents. Um There's a lot of a mantra I think outside in the community where if patients have systolic size and 100 all your medications and uh we'll have a lot of people holding their meds in the morning and in the evening due to that. And I think again, as long as your blood pressure, it's low, but you have asymptomatic, you're not lightheaded, you're not dizzy, then you keep your medication. So we try to retrain our patients not to go by the blood pressure number, but go by symptoms, otherwise they will be holding all of your medications and then they are really not being optimized. Uh finally, troponin levels, they usually get checked when patients get admitted. We really don't trend them or follow them again when they hit the emergency department with heart failure or chest pain. They always have a troponin but definitely having a higher troponin potential. Also worse prognosis. So again, those are five things that you can take a look when patients get admitted and we'll give you some prediction of more child in this patient. So how do we evaluate and match these patients with acute they compensated. Heart felt was the most dynamic assessment. So a few things you can first get a good clinical history and science and symptoms again is the company it keeps okay. Don't go by just one number but go by the group of symptoms that these patients are bringing to the table. Like last night. I got called because somebody robbed their blood pressure, whatever, completely symptom and all of that all sides were normal. So you really need to focus on um the company keeps. So this is, for example, to Two different patients, a 60 year old man with a long history of heart failure. That comes with three weeks of gradually worsening symptoms. And they are relatively high potency. But they have a very delayed cardiomyopathy along sexual look pretty clear. And again, we know that they have a Although Ejection fraction compared to an 80 year old woman with long history, hypertension coming with one hour of symptoms. Uh, so the onset of symptoms with becomes hypertensive. So the again the the presentation will be might be different and the therapeutics will be different. But you need to pay attention to who is the patient, present your planet. And there's three um him a dynamic parameters that you need to look into and they're gonna be altered. So it's other an issue with pre load. So they have increased filling pressures, increasingly be increased our a um increased pulmonary capillary wedge pressure. Or is an issue with after load? You know, you have increased resistance, you have increased SVR always an issue with conductivity. So it's other at least one of the three, if not the three of them. So you have to try to determine that when you see a patient, what is going on. This is a pre load issue is in after load issue. It's a contract bility issue. Is that A mixture of two or 3 of these parameters? So from the filling pressures perspective from the preload perspective, you know, you're filling pressures, you know, your usual numbers. So um when you look into filling pressures that you need to know what what what is normal. When you look into cardiac output, you need to know what's normal. So here we have different um measurements of al put our term evolution or fake and figure is the one that you can actually calculate the bad side. If you have Uh some information, I will go over over that in a few uh in a few slides. So here the cardiac index at least depending on the book, you might have different um um different ranges which most most of books will take 2.2 as the normal cardiac index or above. Again, you can have different sizes. You can have Shaquille O'neal and tattoo. And they're going to have uh maybe similar cardiac output. That's why it's so important to have an index because the that goes into body surface area and then the final you have the measure measurements of resistance, which is either the SVR systemic vascular resistance or the home. And I vascular system. So, um again, decided three things that you want to look for him. A dynamic perspective of their pre load with the filling pressures is the contract ability with the cardiac output and index and the after load with the measurements of resistance. So, I think Barack mentioned or showed the um the human genomic profiles for Stevenson profiles is from late Warner Stevenson, who was at the Brigham for many years now. She's on Vanderbilt. So there's four profiles that you can assess at the bedside and importance of this is if you had this, then you can decide what your therapeutic is going to be. These profiles take two things into consideration. It's not perfect. It doesn't include as we are or systemic vascular system, but it gives you a lot of information. So whether you are congested or not, and that's where that estimated wedge of 22 or you are well or not refuse. So either you're dry or what or either your warm or cold. So the ideal circumstance ideal aerodynamic profile is the profile A. That means you're warm and you're dry. The garden. The most common garden variety representation. You're gonna see the clinic is profiled B you're warm and wet. So you have increased for the pressures. The profile says he's the one that we see here a fair amount which is cold and wet. So you have uh law cardiac um index uh makes you call and then you're congested that makes you wet. And they found the worst of the profiles which is profile L which is cold and dry. You will only have low cardiac index, but also you're feeling pressure is actually normal. So, you know, if you know those cardiac uh does him a dynamic profiles, you actually know what therapeutics you'll need for two to get to a profile. A so If you're warm and wet, usually again, patients come with, you know, the conference at heart failure to look warm, look wet. You know, they went up on their way by £5, 10. They cannot lay flat in bed. They have also been, et cetera. Then you know, you need to dry them as long as they're warm um meaning that they have normal cardiac um in the um uh if you have the profile sees or l that you should associated with cardiogenic shock, where you need to know only to dry them. But you also need to warn them. So you need to make them from cold to warm and you need to make them from wet to wet to drive. So most of these patients, if you can assess that at the bedside, then they not only need the heretics. They also need either either trump's or vascular later therapy. So um I think it's the the slide that you saw from paragraph you um Talks before. So this again, this gives you the 14 economic profiles. The one thing that is not included is the SVR systemic vascular resistance. And the tip for this is really those patients who have higher blood pressure than what is expected. So you have someone with an ejection fraction of 10 or 20% and their blood pressure is 1 21 31 40. So that will give you a clue that their SVR it's high. So the way I explained this to patients is that you know if you have a small straw and you have to blow through it, it's very hard to blow through. You have to put a lot of pressure compared to how bigger stronger. And you can blow and uh with with less resistance. So when you have high resistance your pump your heart it won't be able to pump against a higher resistance. So you need to lower that that resistance. And that's why you use after reducing agents. So Profile A is what we wanted to have. We want to have patients warm and dry. Profile be the most common um profile you're gonna see in the community. You have patients with normal or low cardiac output. They might have normal or high systemic vascular resistance but definitely have increased filling pressures profile. See these are patients that you can consider in cardiogenic shock. They have low cardiac output, They have increased filling pressures and they might have increased systemic vascular resistance. And finally profile ale, which is the most sick of all of them. They definitely have low cardiac output. They have increased or normal systemic passport system but they're filling pressures are normal and this is the patient that we tend to see Most commonly in advance are still 20. And again we have a profile B minus that we can have created here that it's uh you know it's those patients who are not um are kind of lukewarm, you know the cartographic was slow but definitely there's systemic vascular disease thing is hot again. Usually they'll present with higher blood pressure than what you expect. And I definitely have increased filling pressures. So those are patients that will benefit from using these two profiles. So if you know the thermodynamic profile, you know exactly how to treat them. So if you call me and say I have a patient with acute and chronic by ventricular heart failure with reduced ejection fraction. Um and they have A profile B or profile. See I know exactly what kind of person you're talking about. You don't need to give me the whole picture of all you have leg swelling and they have they have um um you know, liver congestion again, you tell me the profound, I know exactly what kind of uh therapeutic they need. Hey, hold on, this is this is Ron uh if you go back to the slide for the audience, how do people transition from A. To B to C to L. Is it 1 to 1 or can somebody go A to C. Or B. L. How does that work for other public? Yeah. So actually we have a slide on that in a little bit. But in general again this is where you wanna go, where you will be profile eight. You want to be warm and you want to be dry. So most patients are going to present with profile beats or they're wet but they're warm, meaning that they have enough profusion to their vital organs. So in this patient you should see normal kidney function or or ideally you should see normal kidney function. You shouldn't see any signs of um an organ perfusion issues. You know, liver congestion or or liver failure should see these patients actually with and you know, with good intentions are just wet. So these are patients, you can just dry, you can give the ratings and you can get from a profile beach profile a profile. See again they're cold and wet so you cannot just dry them. If you put up uh 200 mg of Lasix in the ivy peripherally, it's gonna stay there, there's no circulation. So you need to increase the circulation, you increase the former flow, you need to get there from profile, see to profile be and how do you do you do that? Well, you only Dyna trucks, you need to warm them up. You need to increase the circulation and concomitant. You can do diuretics but you have to warm them up. Otherwise the uh whatever directed you're giving is gonna stay um in the end it's not, I'm gonna circulate. And then Profile ale. Actually those are the most sequence. Usually you need to get them from being cold to be warm and sometimes actually need to give fluids because they're they're dry. So but you need to be very gentle doing that. So this uh again, these two profiles down here, those are profiles that you might need to start considering um mechanical support, therefore mechanical support. Those are technical and cardiogenic shock. So, um again, when patients come here or come to your clinic and they already have symptoms of heart failure that you're only seeing the tip of the iceberg. You're not seeing what has happened uh previously in the past few days to weeks. And that's why some of these new devices or um him a dynamic monitoring that we have remotely. They can help too discern when that that or part of that that iceberg that you're only seeing the tip of it. So why do people uh you know, have accused the compensated um heart failure? Well, most of the times it's non compliance, you know, they don't take their medications. Sometimes they again have dietary administrations and that's very common. We do a lot of teachers in terms of fluid and salt restriction. So it's not uncommon that once we fix that they stop having visits to the emergency. So we talk about cell restriction no more than 2000 mg of salt today and fluid restriction more than 50 ounces. Many patients will come here saying, well my doctor told me I need to flush my kidneys or I need to take at least um you know a glass of water a day. Well that's for a normal heart. If you have heart failure you you have to have a fluid restriction. How much? Well it depends on your physical activity, depends on your size. You're gonna have the same Third restriction for tattooed and for Shaquille O'Neal. But there has to be some sort of limit. So we usually say 50 oz on patients many 60 or even 70 oz. But there has to be some restriction poorly controlled hypertension. Again in ischemic event or a C. S. Uh I just have a patient that was very stable with an ejection fraction of 20% for four years. Very functional and white functional class one or two. And he had a fit last week and he kind of went down the drain. So now we we have money in Pella and we had to do a lot of therapy so so uh you know patients can be stable and and the reason they can really push you over the edge infections the same issue is physiological stress space and of course worsening renal functions. So um why do um again people get readmitted for heart failure. Again diet non compliance and medication and compliance are the most we put them together the most common reasons. And then yeah you will hear a lot of about cardio renal syndrome in heart failure. Again, these are patients who is not uncommon that you try to drive patients, you're giving the right amount of diuretics and they still are not um, pulling through. They still have signs of decreased cardiac output. And then when they come for your next visit, the kidney function is worse. So in general, those patients have decreased cardiac output due to your home and activation, diminished blood flow to the kidneys. So that means decreased uh, profusion. So what that's going to tell its imperial function, increased water and certain retention, increase carded performance. So we will see a far about these these patients and once you warm them up you or use the right amount of medications or after reducing agent, etcetera, Then um, like kidney function starts getting better. So, um, we talk about the three thermodynamic parameters in terms of what to look for. But what are the symptoms and signs are looking for? Well, hi filling pressures. So how do you know that? At the bedside? Well again, again the company keeps, no patients are telling you they have Disney exertion, they had PN They lay flat in bed and they have to wake up 34 hours later and have to kind of go in a tripod position or open their windows and get out breath of air. Have orthodontia have leg swelling, abdominal fullness. Some of them actually come with nausea and vomiting and and the first reaction when they come to the emergency is to give them fluids because they're dry. But you know if you examine the patient actually they're wet so they have um abdominal distension, have gastric congestion and that's why they feel nauseous. I'm waking again. Always, always look at trends. So if someone has a weight of £150 and certainly have 1 61 70 even if their blood pressure is low again examined the patient and actually the volume overloaded again they're gonna be to keep nick or hypoxic cardiac wise and exam. They may have like a cardiac history of course elevated BP about the jugular reflux or pulls out the liver. So make sure you touch the, you examine the album and look for that liver. Um prominent perspective, crackles or decreased breath sounds. But I'll show an example that sometimes the longest time is completely normal and then of course abdominal or lower extremity swelling. Um Looking into low upward state, low cardiac index, you're gonna have hypertension and also regular thready pulse meditation is going to be affected. So these patients come stupor roles become lethargic. They fall asleep when they're talking to you and you know you you put them on a truck so with and improve their Kartik up with an index and so there there's no they're bright and awake. So that's a very common presentation that we see here for low output. And you know, touch their skin, touch their legs, they look clammy, They look cool. I mean not even cool, cold. You know, you're touching their their feet with your daughter some of your hand and they're cold and once you warm them up there like suddenly are warm. So that's uh you know, you need to touch patients, you need to make sure that you examine them appropriately and not just go by the extra of the BMT because otherwise you'll miss a lot of information and I'll tell you for example, they have decreased during out but that's another sign of low, low output. And we talked about the highest we are again the blood pressure is going to be relatively normal even high for what respecting. Also they might have lukewarm extremities and and again decreased urine output. Very important when you examine patients that you look at the jugular veins and again you know you can have these examples like this that you know that you can see that from a mile away. But the truth is that you need to examine patients and I think 80% of the time you can really assess um if somebody's wet if somebody is volume overloaded just like having a J. V. P. So make sure that you start with the patients standing straight or sitting straight. I think most of the books will tell you that the patient needs to be at 45 degrees. But if you have patience of 45 degrees and the J. V. P. Is high and now might be even higher so you might not be able to see it. But again the company keeps patients telling you they kind of lay flat they they feel the game £20 away. Uh they stopped taking the pill. So if you put everything together you expect that that GDP is going to be high. So again most patients unless they're obese or or have a picnic you might not be able to see it but if you pay good attention that you should be able to see it and if you don't see it while standing uh well standing straight up then you start putting them down at some point you're going to see it. Especially if it's slow at some point when you start putting them fly on the bed you might start seeing those neck veins kind of pop up so you need to make sure you pay attention to that. Um Again there's some caveats of course. Um Usually the jugular venous pressure is gonna reflect left sided filling pressures but watch out for situations where it might not like lung disease, obesity, patients with pulmonary embolism or even a customized that should have are being for. Um there's a lot of practical tips when assessing JPP. And you can take a look at this paper from Thibodaux uh from 2018. The reference will be in the slides but it is important to know that from many of the clinical findings that you you can see on the patient, you know, rails and oedema and or Slovenia or even how about you go reflux? The J. B. P. S. Really the one that's gonna have the most sensitivity and specificity. Also one that is very common to spend. W impatient will tell you. I kind of like uh kind of tie my shoelaces, I'm gonna put my socks on and they're just telling you in front of your face. I have been dubbed so patients bend over like this or even you can even do the test when there in your clinic just have them bend over and see if they lose their breath again somewhat. They might be obese etcetera. But I think this is a good a good way to know if they if they have volume overload Um again sensitivity of other physical exam, finances poor okay rails briefly. Oedema is three. All of them all of them might be helpful but they might be absent just to give an example. This is someone who came on July 24 and he was transferred to another institution and I see him and this is his X. So if you see the X ray well there's a look a bit wet. Yeah. I mean is this a 57 50 50 kg patient? And you of course you can see the huge garden megalith there. And the anti pro Bmp was very high but long for clear. So many of the space. Especially those with compensated chronic heart failure that come now the compensated. They might have a complete clear long. So it I will say it's rare for me to hear rails unless they have um new diagnosis of life. Solid heart failure. But and especially already came with the bureau. Mean I'm Melbourne on and when I talked to his extremities actually he was called He had like plus one pitting oedema. And even with that I was able to that reason from 57 kg to 50 kg in five days without a swan. How did I do that? Well you examine the patient you know that I have some pitting edema on the legs but also he had a very prominent happen to you gonna reflux and the visa and the other men can hold a lot of fluid so make sure that you um no examine the J. V. P. But also try to palpate deliver and if you can squeeze that liver and you see that gbp going up on their neck they're still wet. Okay so this is someone who I kept pressing on the abdomen every morning and you know I saw that uh hypothetically horrific kind of pop up on his neck so he was volume overloaded and we got seven kg kilograms out of him Without us one. So make sure that you examine the patient properly every morning And right now the patient actually is waiting for a transplant. You can see here in Pella 5.5 and he's you know, he's walking with impeller. We try to put this um machines axillary with an axillary approach and I guess some patients they may have medical management and they can be stable but some definitely need mechanical support. Um Again we spoke about um what to look for if you have an elevated right atrial pressure or are you looking for left side or right side heart failure? Look for the symptoms the symptoms might indicate if it's left sided, only right sided only or by ventricular failure. So look for them and again the clinical examination it's important. So assess for congestion. Are the right sided heart failure? Left side heart failure of both. Okay. And as for Locarno gap you have cold extreme because you touch them and they're really cold or lukewarm to your to your hand or are they warm their warm? You can at least tell from the bedside that likely they have normal cardiac index. Okay. Um so again, how to match him? A dynamic abnormalities. We went over the symptoms science. We went over the normal values. So if you have increased pre load you need diuretics to reduce foot volume. If you have um um after after all the issues, no increase systemic vascular resistance. You can use vassal dilator. And then if you have low cardiac index you have I know trucks, dog bank contract ability. Again this is part of that what rana's before we cannot make a profile. See a profile A I mean you cannot make someone who is called and what you can make them warm and dry directly. Okay. You need to go from profile see to profile A with the use of psychotropic supports and sometimes faster than the layers. Especially if you can um If you suspect that they have um increased systemic vascular resistance. If you have a swelling of course you can calculate it. Um But um many I think many practices are afraid of using Ambassador later especially when the blood pressure is low. Uh And the trick for that is that if your um your tank is full if you're um filling pressures are high you can see the J. V. P. You have signs of intravascular volume overload again. You can use this basket that leaders you have to be careful. You can of course you start with start with a small dose and then update trade. But many patients that we see here um they benefit from vascular later. So you need to you can use them on those patients with profile see that you feel that there is very high again profile l usually you need to warm them up and sometimes you need to give fluid back to help with the Kartik index and profile. Be in general just ivy diuretics should be sufficient but you need to give the right amount you cannot give us um you cannot under those. And that's one of the big troubles that we see with many practices when they refer patients here. They're giving Lasix you know for us in my 40 mg, maybe 80 mg. but the truth is that they need more than that and just to give you an idea you can use up to 400 mg in one those. Um We just be your next year a lot because they have um allowed better by availability. So we tend to use it and it's always important if you're admitting a patient with heart failure you need to that is them ivy not pio unless your transition to people because you got discharged them. Sometimes if their profile B and you want to speed up their diaries is you could potentially add Chinatrust. But again this is more for profile B minus or profile. See uh we talked about that profile B minus. Again usually the SVR it's hot. How about other ways? So this is the main talk is really how you can assess at the bedside. What is there any more than I'm profiled? Let's say that you have other tools like a swanky as well. You know we use a fair amount of spangles. I know some practices have issues placing swan gas either because of the the practice and used to it or the nursing stuff is not used to it. But sometimes you really need a swan too. Tell you more information. Especially they're not responding to your initial assessment of the beds are for the from the human genomic profile. So um if you cannot have a slam you can always also put a picc line which is again very full inserted. And with that you can obtain a BBg a venus blood cast and obtain their makes venus auction situation which is a A surrogate or of whom four months way of assessing their cardiac output. Um Or even if they have a triple lumen catheter that was placed for central access, you can also take a venus blood cast and assess their sdo too. Okay. But if you um if you need more information from the human dynamic perspective again the swan Ganz really the way the way to go. Um Many places will have a procedure room to put it in. Sometimes they go into the I. C. U. And have them in place there. If you have anybody to go into the cafta because they're getting a coronary angiogram because they came with chest pain and the companies that heart failure you can always ask interventional is to do around her cat on the spot. Or even against at least get an L. G. D. P. Just crossing the arctic valve. Again that L. GDP will be helpful to have that piece of information so you can at least have some thermodynamic parameters of what what do you what do you need to do? Uh Once you have that you can do your calculations cardiac output index. Yes we are on tv are but even if if the only thing that you have is a big line you can still calculate your cardiac output. Uh if you have your venus blood cast. Okay? There's many apps that you can you don't need to use all this big formula. There's many apps you can use to calculate your cardiac output at the bedside. We spoke about the Carl Icahn fertility. Again you need to look beyond the E. F. I have people with the F. Of 10 20% are very functional. Uh Ny che function plus one or two and have people with the F of 30 40%. That can only walk from a few feet before they get symptomatic. Okay so again it's part of the equation but it's not all of it. Especially you need to take into consideration only the EF. But any associate available open these mitral regurgitation, arctic stenosis, try cause regurgitation. So those are things that also play a role. So people tend to fixate on the ef but it's not the whole um the whole picture. And again if you can get one single piece of information and someone who gets admitted for her failure, if you can put a picc line or they have a triple lumen catheter on their neck you can obtain a mix venus socks and situation. Okay? And what that's going to give you as a surrogate for cardiac output is a poor month way of getting the idea of the cardiac output. So if you have um you just put it slow or you calculate the cardiac output is slow and your S. U. Two is slow then that's low up with syndrome. So you have heart failure. Pe hyperbole mia. If you're have low cardiac Applebee S. P. 02 is high then that could be um anesthesia hypothermia. Again this is somewhat unusual if your cardio apple is actually high. But you ask you to slow then look into what can cause your respiratory below anemia hypoglycemia or high vo two. And then if you have a high cardiac output, s. U. two is high usually. Um This includes sex is I mean that's the thing that comes to our mind senses or some high output state. Um So again four things that can cause you're dropping your s you to either you don't have enough cardiac output. Your hemoglobin is slow to make sure that these patients might need to be transfused. And they ask you to make a high uh Such sats are low, people have pulmonary disease or boxing consumption is increased without an increase in oxygen delivery. That's usually uh hyper dynamic states or sepsis. One of the things you have available cardiograms um Again this is a device that you can, it can be placed in the pulmonary artery is um it helps to remotely monitor these patients and it does reduce heart failure admissions. It does improve quality of life is usually indicate for people with nyC class three, it does not improve survival, but it's a tool that it's available. And the reason why it's helpful is because it might give you idea about the filling pressures before patients get symptomatic. So this is a way to actually act before they have clinical symptoms. Okay, the tip of the iceberg Um as you know, since July one, coverage for from Medicare to place these devices here in in Florida. Other ways that you can access to him a dynamic profile. Uh Most patients that have had threats are going to have a device. Many of these devices have into Jurassic impedance or optimal. So some clinics will have a monitor in there there um clinic that they can get interrogated also you know that the patient has your device interrogated a few days for a few weeks before. You can also look into the optimal and they can tell you the impedance. So they that will give you a fluid threshold and also you can give you give you information about the behavior of this patient from a fluid perspective. Uh Some clinics will have especially hard filler place will have some uh impedance um um of the devices that can measure impedance. Um Externally again we don't have them here we just go by our physical exam or and our company keeps. So but definitely there's there's a new set of devices like this that will measure your impedance. Um If you are into a point of care ultrasound of focus you can also look into the I. V. C. So definitely the wider diabesity you can, it correlates with fluid overload. So that's another way. And again the bigger the that the iBc that also is associated with the event free survival like in this graph or where those patients have very delighted um Ibc compared to the other groups. So that's another way if you can you have an ultrasound uh And the other way that look into is looking at the lungs. You know you look for those be lies. And the way I interpret this is like you know you're in florida you're under in a pool. Your your eyes open inside the pool and then you're looking at that those rays of sun coming into the pool. That's pretty much how it looks when you have fluid. You have this D. Lies on the long Frankie map that represent fluid. So if you're into a point of care ultrasound that's a way to look into it. And this was also a nice paper published in Jack cardiovascular imaging a couple of years ago. Looking at at it and looking at what windows you can get to assess for it not only in your bedside practice but also even when you for there's some data on stress echocardiography and and seeing if these lines up here during stress. So um again you can define if they have right heart failure, left heart failure or their normal and famous with other devices you can have this stress be lines to start appearing when patients are asymptomatic before the full cascade. So again looking at the tip of the iceberg. So to finish off again, take on messages, assess your patient, get the hmp. Okay. The company keeps look at what else is going on with them. Clinical, assess the better exam and and and try to assess the hydrodynamic profile. The company keeps, make sure you just try and look at the weight and the prior clinic visit. Look at the other way if they have recordings of their way because that will give you a lot of information. Same with trends in labs, don't under joseph. Your tank is full, you're full of fluid, make sure your diaries with the right amount. If you are uncertain about the thermodynamic profile or they're not responding to the swan guns and many of these patients, you might need temporary mechanical support. Can sometimes you can't you cannot just fix with mets so make sure you know when to hit the the bottom for these devices. So with that we'll finish.
