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Time for another #VExUS #POCUS case: A pt with known severe CHF presents with abdominal pain and receives fluids (~1L). Later develops AKI, hyper K.
NOTE: has trace edema; no c/o weight gain
Here is what #echofirst and venous #Doppler show. #MedEd #thread 👇
1/ Apical 4 chamber
2/ Note the smoke (spontaneous echo contrast) on the left. Also, LA is huge. Another one 👇
3/ PLAX view #POCUS
Note left pleural effusion (fluid posterior to descending aorta)
4/ We already know pt has CHF. What's the question? - does he need fluids for AKI? (especially as there is no weight gain/worsening edema/shortness of breath)
Let's take a look at the IVC (short axis) #POCUS 👇
5/ It's big, relatively round. Doesn't appear to collapse much with respiration. There is smoke here as well (sluggish circulation)
6/ Time for #VExUS #POCUS
1st: Hepatic vein Doppler - only D-wave below the baseline = severe congestion
7/ Portal vein - 100% pulsatile
8/ Intrarenal vein:
venous flow predominantly in diastole = severe congestion = likely congestive acute renal failure
9/ our @Pocus101 calculator agrees with severe congestion
Point I'm trying to make: Don't rely on weight/pedal edema in CHF patients to make decisions about fluids. Fluid redistribution drives pulmonary manifestations than overt fluid accumulation in a significant proportion of patients with acute HF.
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