UMEM Educational Pearls

Title: VExUS to Detect Venous Congestion

Keywords: resuscitation, ultrasound, VExUS, venous congestion (PubMed Search)

Posted: 9/8/2020 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

While the invasive monitoring of central venous pressure (CVP) in the critically ill septic patient has gone the way of also transfusing them to a hemoglobin of 10 mg/dL, it remains that an elevated CVP is associated with higher mortality^1,2 and renal failure.^2,3

Extrapolating from existing data looking at hepatic vein, portal vein, and renal vein pulsatility as measures of systemic venous hypertension and congestion,^4,5,6 Beaubien-Souligny et al. developed the venous excess ultrasound (VExUS) grading system incorporating assessment of all 3, plus the IVC, using US to stage severity of venous congestion in post-cardiac surgery patients.⁷ They evaluated several variations, determining that the VExUS-C grading system was most predictive of subsequent renal dysfunction.

(Image from www.pocus101.com)

High Points

VExUS Grade 3 (severe) venous congestion:

Correlated with higher CVP & NTproBNP levels, as well as overall fluid balance
Had a 96% specificity for development of subsequent AKI

Caveats

Evaluating all parameters yields the most benefit to avoid false positives
Can be difficult to obtain all views (>25% of subjects excluded due to poor US image quality)
Studied in a limited population, notably not primarily RV failure patients

Clinical Uses

To limit harmful fluid administration in shock
To help answer the prerenal vs cardiorenal AKI question in CHF
To indicate when volume removal (diuresis) should be the strategy, even in patients with vasopressor-dependent shock

A great how-to can be found here:

https://www.pocus101.com/vexus-ultrasound-score-fluid-overload-and-venous-congestion-assessment/

References

1. Li DK, Wang XT, Liu DW. Association between elevated central venous pressure and outcomes in critically ill patients. Ann Intensive Care. 2017;7(1):83. doi:10.1186/s13613-017-0306-1

2. Chen KP, Cavender S, Lee J, et al. Peripheral Edema, Central Venous Pressure, and Risk of AKI in Critical Illness. Clin J Am Soc Nephrol. 2016;11(4):602-608.

3. Chen CY, Zhou Y, Wang P, Qi EY, Gu WJ. Elevated central venous pressure is associated with increased mortality and acute kidney injury in critically ill patients: a meta-analysis. Crit Care. 2020;24(1):80. doi:10.1186/s13054-020-2770-5

4. Iida N, Seo Y, Sai S, et al. Clinical Implications of Intrarenal Hemodynamic Evaluation by Doppler Ultrasonography in Heart Failure. JACC Heart Fail. 2016;4(8):674-682. doi:10.1016/j.jchf.2016.03.016

5. Ikeda Y, Ishii S, Yazaki M, et al. Portal congestion and intestinal edema in hospitalized patients with heart failure. Heart Vessels. 2018;33(7):740-751. doi:10.1007/s00380-018-1117-5.

6. Beaubien-Souligny W, Benkreira A, Robillard P, et al. Alterations in Portal Vein Flow and Intrarenal Venous Flow Are Associated With Acute Kidney Injury After Cardiac Surgery: A Prospective Observational Cohort Study. J Am Heart Assoc. 2018;7(19):e009961. doi:10.1161/JAHA.118.009961

7. Beaubien-Souligny W, Rola P, Haycock K, et al. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J. 2020;12(1):16. doi:10.1186/s13089-020-00163-w