Coexistence of a fluid responsive state and venous congestion signals in critically ill patients: a multicenter observational proof-of-concept study

Abstract

Background Current recommendations support guiding fluid resuscitation through the assessment of fluid responsiveness. Recently, the concept of fluid tolerance and the prevention of venous congestion (VC) have emerged as relevant aspects to be considered to avoid potentially deleterious side effects of fluid resuscitation. However, there is paucity of data on the relationship of fluid responsiveness and VC. This study aims to compare the prevalence of venous congestion in fluid responsive and fluid unresponsive critically ill patients after intensive care (ICU) admission. Methods Multicenter, prospective cross-sectional observational study conducted in three medical–surgical ICUs in Chile. Consecutive mechanically ventilated patients that required vasopressors and admitted < 24 h to ICU were included between November 2022 and June 2023. Patients were assessed simultaneously for fluid responsiveness and VC at a single timepoint. Fluid responsiveness status, VC signals such as central venous pressure, estimation of left ventricular filling pressures, lung, and abdominal ultrasound congestion indexes and relevant clinical data were collected. Results Ninety patients were included. Median age was 63 [45–71] years old, and median SOFA score was 9 [7–11]. Thirty-eight percent of the patients were fluid responsive (FR+), while 62% were fluid unresponsive (FR−). The most prevalent diagnosis was sepsis (41%) followed by respiratory failure (22%). The prevalence of at least one VC signal was not significantly different between FR+ and FR− groups (53% vs. 57%, p = 0.69), as well as the proportion of patients with 2 or 3 VC signals (15% vs. 21%, p = 0.4). We found no association between fluid balance, CRT status, or diagnostic group and the presence of VC signals. Conclusions Venous congestion signals were prevalent in both fluid responsive and unresponsive critically ill patients. The presence of venous congestion was not associated with fluid balance or diagnostic group. Further studies should assess the clinical relevance of these results and their potential impact on resuscitation and monitoring practices.

SOP Abschätzung des Volumenbedarfs mittels POCUS

“…Mittlerweile wissen wir, dass Volumenüberladung mit vermehrtem Auftreten von Organversagen, akuter Nierenschädigung, prolongierter mechanischer Beatmung und Tod assoziiert ist. Bei venöser Kongestion kann eine zusätzliche Volumengabe schaden, weshalb hier auch von Volumenintoleranz gesprochen wird [7,8,9,10,11,12]. ▶ Abb.…”

Dynamic changes of hepatic vein Doppler velocities predict preload responsiveness in mechanically ventilated critically ill patients

“…As proposed by Kenny et al, the dynamic assessment of waveform patterns (i.e., increase in D wave or reversion of S wave) through a PLR maneuver or fluid challenge could aid in identifying potential congestion [ 39 , 40 ]. Thus, HVD could be a fairly unique tool able to assess not only fluid responsiveness as seen this manuscript, but also assess fluid tolerance, which is of growing clinical importance [ 41 , 42 ]. Moreover, future research efforts should answer these areas of uncertainty.…”

Challenging ICU dogmas: a new perspective on venous congestion and preload dependency

“…We are writing to extend our sincere congratulations to Muñoz et al for their insightful recent study [ 1 ]. Their exploration of the coexistence of preload dependency and venous congestion in ICU patients, as estimated by a specific score, introduces a novel approach to the often-misunderstood dynamics of congestion in critically ill patients.…”