NephroPOCUS Profile picture
19 May, 18 tweets, 13 min read
Time to discuss some rationale/evidence behind doing #VExUS #POCUS #Nephrology
A short #tweetorial #MedEd πŸ‘‡
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 πŸ‘‡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 πŸ‘‡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 πŸ‘‡)
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
14/ Future directions:
Femoral/splenic veins may be used as an adjunct in the assessment of venous congestion.
#VExUS #POCUS
ncbi.nlm.nih.gov/pmc/articles/P…
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…
17/ Another observational study in progress incorporating multiple #POCUS #VExUS parameters including the femoral vein.
clinicaltrials.gov/ct2/show/NCT04…
18/
If there is anybody who hasn't seen my pinned tweet, it is a collection of 30+ #VExUS tweets by various twitter educators. Have a look.

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More from @NephroP

24 Apr
#POCUS #echofirst #MedEd case of the day.
Context: alcoholic liver cirrhosis with suspected #hepatorenal syndrome
Purpose: think about the underlying pathophysiology & seek expert input
1/ PLAX, PSAX, Apical views of the heart. Heart rate ~110-116 bpm
#VExUS images in 🧡
2/ overall, looks hyperdynamic. LA looks little enlarged on PLAX, visual TAPSE high on apical.
In cirrhosis, hyperdynamic circulation is expected because of splanchnic vasodilatation and 'relative' arterial under filling.
LV EF #POCUS obtained using @kosmosplatform πŸ‘‡
3/ Lets calculate stroke volume using LVOT VTI #POCUS
It looks supra-normal
Read 20 tweets
23 Apr
OK #VExUS #POCUS enthusiasts, time for another case discussion.
Somebody asked if I ever recommend IV fluid in a patient with #VExUS 3.
Here is one example where I did.
1/ First, let's see the #physicalexam (#IMPOCUS) findings, then will tell about the case. #MedEd #Nephrology
2/ So, hepatic shows D-only patternπŸ‘†
If we are doing #VExUS, IVC must be big. Here is the M-mode #POCUS πŸ‘‡
3/ Renal parenchymal vein #VExUS #POCUS
It also demonstrates D-only pattern πŸ‘‡
Read 15 tweets
21 Apr
#POCUS quiz of the day:
Easy one. Identify 1, 2 and 3.
POLL in thread πŸ‘‡ #IMPOCUS #MedEd
πŸ‘†#POCUS
PE = pleural effusion
PER = pericardial effusion
Ao = aorta
IVC = inferior vena cava
Rt = right
Lt = left
Correct answer: option 2 -
1. left pleural effusion (note the appearance of collapsed lung; also u can see rib shadows/posterior chest wall = lung area)
2. Right pleural effusion (remember the Boomerang sign on subxiphoid view?)
3. IVC
Read 4 tweets
9 Apr
Time for a #POCUS #tweetorial on optimization of Doppler. Very important for #VExUS enthusiasts. #MedEd
1/ Unlike greyscale imaging which depends on amplitude of the returned signal, Doppler depends on frequency information. This graphic explains why perpendicular angle is bad.
2/ other way of saying this, in relevance to color Doppler #POCUS
RBC moving away from the probe = Fr<Ft = negative Doppler shift = Blue color
RBC moving towards = Fr>Ft = positive Doppler shift = Red color
Rest of the images/videos from this excellent paper: pubs.rsna.org/doi/10.1148/rg…
3/ Anatomy (components) of a spectral Doppler waveform (carotid shown)πŸ‘‡
Above baseline is like red on color (towards probe), below = blue. As 0 degree angle is not always possible, <60 is considered OK.
Read 19 tweets
8 Apr
@khaycock2 @ArgaizR @katiewiskar @ThinkingCC
Any comments on this portal vein pulsatility obtained from a pt with cirrhosis? (Why prox is more pulsatile?)
No cardiac issue that I know of; was reviewing rad-performed images πŸ€”
Splenic seems to be fine, looks more like that of distal portal.
Hepatics
Read 4 tweets
6 Apr
1/ Thought of doing a quick #tweetorial on image acquisition for #POCUS friends starting to do #VExUS
It's kind of "how I do it" guide and not necessarily optimized for research.
1st: Look at the IVC in both long and short axes
If big, do further scans πŸ‘‡ #MedEd #FOAMed
2/ Lateral approach works best to obtain a straight segment of the portal vein (straight = best Doppler shift) and a nice hepatic vein too.
Place transducer approximately in the anterior axillary line pointing towards sternal notch. Then fan antero-posteriorly.
#POCUS #VExUS
3/ Forgot what is fanning?
Its also called tilting or some people say, "look" in a particular direction from the same spot.
#POCUS
Read 18 tweets

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