Time to discuss some rationale/evidence behind doing #VExUS#POCUS#Nephrology
A short #tweetorial#MedEd 👇 1/ Is fluid overload harmful?
of course yes. Here is a recent meta-analysis.
2/ Does fluid administration affect renal venous flow in asymptomatic but vulnerable patients (#heartfailure)? #POCUS#VExUS
3/ In fact, elevated CVP is associated with reduced GFR.
This 👇is a study in outpatients undergoing right heart cath (N = 2557). In CVP values >6 mm Hg, a steep decrease in GFR was observed.
4/ Do alterations in intra-renal venous flow bear prognostic significance in heart failure patients? Yes. #VExUS
5/ More recent study looking at the effect of change in renal waveform pattern on prognosis. #VExUS#POCUS
6/ Can intra-renal Doppler predict prognosis in patients with chronic pulmonary hypertension? Yes.
Here is a study 👇looking at renal venous stasis index (probably this index is better in chronic settings than observing the pattern) #VExUS#POCUS
7/ Does decongestive therapy normalize the intra-renal venous flow pattern in patients hospitalized for acute heart failure? Yes. #POCUS#VExUS onlinejcf.com/article/S1071-…
8/ How about portal vein? It is easier to obtain than intra-renal #VExUS
Does it predict AKI? Yes (in cardiac surgery patients 👇)
This is actually the parent study of the VExUS paper (multi-vein congestion assessment)
9/ Does the portal vein flow change dynamically during Decongestion in Patients with #heartfailure and Cardio-Renal Syndrome? Yes.
Here is a recent case series by our own #VExUS ologist @ArgaizR karger.com/Article/FullTe…
10/ Another small study in critically ill cardiac ICU patients showing improvement in hepatic/portal vein patterns with decongestive therapy. #POCUS#VExUS
11/ Another study that looked at the hepatic/portal/intra-renal #VExUS in predicting adverse renal events. But this is a general ICU cohort (= patients can have AKI due to other causes/multiple factors; not just congestion)
12/ Finally, the famous #VExUS scoring by @WBeaubien@ThinkingCC@khaycock2 and colleagues.
using IVC #POCUS + hepatic + portal + intra-renal Doppler to quantify venous congestion predicts AKI.
13/ Using multiple points overcomes the inherent limitations of individual components as well as technical issues.
Combined #VExUS score predicts AKI better than IVC #POCUS (CVP) alone
15/ Future directions:
Need clinical trials looking at multiple #POCUS parameters.
16/ Future directions:
A multi-center prospective study is in progress.
"Ultrasound Markers of Organ Congestion in Severe Acute Kidney Injury (ECHO-AKI)" clinicaltrials.gov/ct2/show/NCT04…
#eVExUS (= extended #VExUS) includes evaluation of additional veins when the original 3 veins are unobtainable or unreliable for any reason.
Below👇🧵 is an illustrative case showing abnormal pattern in all these veins.
#POCUS #FOAMed #Nephpearls
1⃣ IVC #ultrasound: dilated
#echofirst views used to evaluate the right heart.
From ASE comprehensive echocardiography textbook/2010 guidelines
#POCUS #MedEd #CriticalCare #IMPOCUS
(🧵of 5 tweets)
Common #echofirst views used in the #POCUS setting, image acquisition pearls and structures visualized.
Thread below🧵
Courtesy, ASE TTE guidelines 2018
#MedEd #FOAMed #FOAMcc
1⃣ Parasternal window
2⃣ Parasternal window continued
3⃣ Parasternal window, short axis plane
Often underutilized, can get an idea of TR when apical window is difficult, can do RVOT Doppler as well
Focused question: Is HTN in a #dialysis patient always⬆️ intravascular volume? Remove💧?
Clinical: ESRD due to polycystic kidney disease, BP 160s/~100, IVC not well-visualized.
Next step to assess RAP: #VExUS
Below is hepatic vein Doppler
#POCUS #Nephpearls #FOAMcc
Follow the🧵 https://t.co/xZe23bHvJVtwitter.com/i/web/status/1…
2/ 👆What do you think?
3/ 👆HV #VExUS is showing resiprophasic D-reversal.
We commonly talk about S-reversal. Where do you see D-reversal? - constrictive pericarditis, tamponade, some cases of severe pulmonary HTN.
Next step: Evaluate the🫀
👇PV looks fine
#POCUS enthusiasts, is this IVC normal, abnormal? (asking about possibilities, not definitive conclusions) #FOAMcc#MedEd#Nephpearls
(Transverse view in thread)
#POCUS answer:
I deliberately avoided clinical context in the original tweet to gather multiple opinions.
Image obtained from a thin, trained athlete with resting HR in 40s-50s.
A dilated IVC is commonly seen in this setting with no right heart pathology. In addition, particulate… twitter.com/i/web/status/1…