Point of Care Ultrasonography for Objective Assessment of Heart Failure: Integration of Cardiac, Vascular, and Extravascular Determinants of Volume Status

Abstract

<b><i>Background:</i></b> Lingering congestion portends poor outcomes in patients with heart failure (HF) and is a key target in their management. Studies have shown that physical exam has low yield in this setting and conventional methods for more precise assessment and monitoring of volume status (e.g., body weight, natriuretic peptides, and chest radiography) have significant inherent shortcomings. <b><i>Summary:</i></b> Point of care ultrasonography (POCUS) is a noninvasive versatile bedside diagnostic tool that enhances the sensitivity of conventional physical examination to gauge congestion in these patients. It also aids in monitoring the efficacy of decongestive therapy and bears prognostic significance. In this narrative review, we discuss the role of focused sonographic assessment of the heart, venous system, and extravascular lung water/ascites (i.e., the pump, pipes, and the leaks) in objective assessment of fluid volume status. <b><i>Key Messages:</i></b> Since each of the discussed components of POCUS has its limitations, a combinational ultrasound evaluation guided by the main clinical features would be the key to reliable assessment and effective management of congestion in patients with HF.

Point‐of‐care Doppler ultrasound in the management of hyponatremia: Another string to nephrologists' Bow

“…POCUS uses a pump, pipes, and leaks schema to assess fluid status as we previously described. 5 The “pump” is the heart, assessed via focused cardiac ultrasound (FoCUS); the “pipes” refer to the IVC and intraabdominal venous system; and “leaks” constitute pulmonary congestion and intra‐abdominal free fluid. FoCUS rapidly assesses pump function in a hypotensive patient by analyzing the “5 Es”: left ventricular ejection, presence or absence of pericardial effusion, equality (relative right ventricular size), entrance (IVC size and collapsibility), and exit (ascending aorta diameter) as described by Kennedy Hall et al 9 Clinicians with advanced training in POCUS can perform additional evaluations such as stroke volume measurement using left ventricular outflow tract pulsed wave Doppler, estimation of right ventricular systolic pressure using tricuspid regurgitant jet continuous wave Doppler, and left ventricular filling pressure assessment using mitral valve pulsed wave and tissue Doppler.…”

“…Clinician‐performed bedside Doppler ultrasonography aids in the objective assessment of a patient's hemodynamic status and, when interpreted in conjunction with laboratory data such as urine electrolytes, can effectively guide therapy in disorders such as hyponatremia. 5 Herein, we present one such case, demonstrating how this can be achieved.…”

POCUS for Nephrologists: Basic Principles and a General Approach

“…Continuous renal replacement therapy was started for acute kidney injury and hypervolemia. During follow up, multi-organ POCUS was performed by the nephrologist to assess volume status and titrate ultrafiltration [16]. While there was a significant improvement in the venous congestion, cardiac ultrasound incidentally showed a mobile, echogenic structure in the right ventricle adherent to sub-valvular apparatus of the tricuspid.…”

A Blueprint for an Integrated Point-of-Care Ultrasound Curriculum for Nephrology Trainees

“…Multi-organ POCUS also aids in the objective assessment of hemodynamics, which is critical when caring for patients with complex fluid and electrolyte aberrancies [6]. Despite the stated applications and learners' desire for additional instruction in sonography, POCUS training in nephrology fellowship programs largely remains a work-in-progress [7].…”