Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system

Abstract

Background: Organ congestion is a mediator of adverse outcomes in critically ill patients. Point-Of-Care ultrasound (POCUS) is widely available and could enable clinicians to detect signs of venous congestion at the bedside. The aim of this study was to develop several grading system prototypes using POCUS and to determine their respective ability to predict acute kidney injury (AKI) after cardiac surgery. This is a post-hoc analysis of a single-center prospective study in 145 patients undergoing cardiac surgery for which repeated daily measurements of hepatic, portal, intra-renal vein Doppler and inferior vena cava (IVC) ultrasound were performed during the first 72 h after surgery. Five prototypes of venous excess ultrasound (VExUS) grading system combining multiple ultrasound markers were developed. Results: The association between each score and AKI was assessed using time-dependant Cox models as well as conventional performance measures of diagnostic testing. A total of 706 ultrasound assessments were analyzed. We found that defining severe venous congestion as the presence of severe flow abnormalities in multiple Doppler patterns with a dilated IVC (≥ 2 cm) showed the strongest association with the development of subsequent AKI compared with other combinations (HR: 3.69 CI 1.65-8.24 p = 0.001). The association remained significant after adjustment for baseline risk of AKI and vasopressor/inotropic support (HR: 2.82 CI 1.21-6.55 p = 0.02). Furthermore, this severe VExUS grade offered a useful positive likelihood ratio (+LR: 6.37 CI 2.19-18.50) when detected at ICU admission, which outperformed central venous pressure measurements. Conclusions: The combination of multiple POCUS markers may identify clinically significant venous congestion.

Doppler Interrogation of the Femoral Vein in the Critically Ill Patient: The Fastest Potential Acoustic Window to Diagnose Right Ventricular Dysfunction?

“…Pulsatile portal flow has also been reported in healthy individuals ( 57 , 58 ), an observation which supports the combination of more than one venous Doppler signal to confirm RV dysfunction or venous congestion ( 59 ). The extent to which the use of the CFV Doppler signal will complement information obtained from the hepatic, portal, and renal venous Doppler signals or the Venous Excess Ultrasound Score ( 59 ) remains to be demonstrated. Finally, abnormal CFV Doppler waveform has been correlated with right heart dysfunction severity in patients with pulmonary embolism and could be used in stratification strategies ( 33 ).…”

The use of venous Doppler to predict adverse kidney events in a general ICU cohort

“…Doppler flow patterns of hepatic veins (HV), portal vein (PV) and intra-renal veins (RV) are noninvasive and accurately identify early stages of right-sided venous congestion in patients who have cardiac dysfunction or have undergone heart surgery. Abnormalities in venous flow patterns after open heart surgery predict AKI, right heart strain and other post-surgical complications [ 6 – 9 ]. Similarly, abnormal flow patterns are consistently measured in congestive heart failure with elevated right atrial pressures [ 10 ].…”

SARS‐CoV‐2–related ARDS in a maintenance hemodialysis patient: case report on tailored approach by daily hemodialysis, noninvasive ventilation, tocilizumab, anxiolytics, and point‐of‐care ultrasound

“…In April 2020, when the patient's clinical trend was improving, the venous excess ultrasound score (VEXUS) was purposed for assessing venous congestion in cardiorenal syndrome, including US examination of IVC diameter and waveforms of hepatic, portal and renal veins, in patients admitted to ICU after cardiac surgery, excluding patients with critical illness, eGFR < 15 mL/min, or renal transplantation 26 . VEXUS score was associated with the risk of acute kidney injury, and subsequently adopted by Bhardwaj et al, 27 for tailoring fluid removal by diuretics and ultrafiltration in patients with cardiorenal syndrome associated with acute kidney injury stage 1 to 3.…”