The management of complex fluid and electrolyte disorders is central to the practice of nephrologists. The sensitivity of physical examination alone to determine fluid status is limited, precluding accurate clinical decision making. Point-of-care ultrasonography (POCUS) is emerging as a valuable, noninvasive, bedside diagnostic tool for objective evaluation of physiologic and hemodynamic parameters related to fluid status, tolerance, and responsiveness. Rapid bedside sonographic evaluation can obtain qualitative data on cardiac function and quantitative data on pulmonary congestion. Advanced POCUS, including goal-directed Doppler echocardiography, provides additional quantitative information, including flow velocities and pressures across the cardiac structures. Recently, abnormal Doppler flow patterns in abdominal organs secondary to increased right atrial pressure have been linked to congestive organ damage, adding another component to the hemodynamic assessment. Integrating POCUS findings with clinical and laboratory data can further elucidate a patient’s hemodynamic status. This drives decisions regarding crystalloid administration or, conversely, diuresis or ultrafiltration and allows tailored therapy for individual patients. In this article, we provide an overview of the focused assessment of cardiovascular function and pulmonary and venous congestion using POCUS and review relevant literature.

The role of venous congestion in abnormal kidney function is being increasingly recognized. It is well known that unresolved congestion is associated with adverse kidney and overall outcomes in patients with heart failure. Similarly, any condition that leads to elevated central venous pressure, such as pulmonary hypertension, can result in impaired kidney perfusion by increasing its afterload. Point-of-care ultrasonography (POCUS) enables the clinician to objectively assess hemodynamics at the bedside and, thereby, guide patient management. Lung POCUS has received widespread attention in the recent past because of the relative ease of the technique, but it reflects only left heart pressures and not venous congestion. Although inferior vena cava POCUS is used to estimate right atrial pressure, its isolated use cannot demonstrate organ congestion. Moreover, it is associated with several technical and conceptual limitations. Recently, venous excess Doppler ultrasound has emerged as a tool to assess venous congestion at the organ level in real time. Severe flow abnormalities in hepatic, portal, and kidney parenchymal veins have shown to predict the risk of congestive kidney injury. In addition, it helps to objectively monitor the efficacy of decongestive therapy. In this review, we provide a brief overview of various components of venous excess Doppler ultrasound and share our perspective on incorporating this novel tool in nephrology practice.

Background: Lingering congestion portends poor outcomes in patients with heart failure (HF) and is a key target in their management. Studies have shown that physical exam has low yield in this setting and conventional methods for more precise assessment and monitoring of volume status (e.g., body weight, natriuretic peptides, and chest radiography) have significant inherent shortcomings. Summary: Point of care ultrasonography (POCUS) is a noninvasive versatile bedside diagnostic tool that enhances the sensitivity of conventional physical examination to gauge congestion in these patients. It also aids in monitoring the efficacy of decongestive therapy and bears prognostic significance. In this narrative review, we discuss the role of focused sonographic assessment of the heart, venous system, and extravascular lung water/ascites (i.e., the pump, pipes, and the leaks) in objective assessment of fluid volume status. Key Messages: Since each of the discussed components of POCUS has its limitations, a combinational ultrasound evaluation guided by the main clinical features would be the key to reliable assessment and effective management of congestion in patients with HF.

Fluid overload has been associated with morbidity and mortality in various clinical scenarios including heart failure and critical illness. It exerts pathologic sequelae in almost all the organ systems. Proper management of patients with fluid overload requires knowledge of the underlying pathophysiology, objective evaluation of volume status, selection of appropriate therapeutic options, and maintenance and modulation of tissue perfusion. There are several methods to appraise volume status but none without limitations. In this review, we discuss the diagnostic utility, prognostic significance, and shortcomings of various bedside tools in the detection of fluid overload and evaluation of hemodynamic status. These include clinical examination, biomarkers, blood volume assessment, bioimpedance analysis, point-of-care ultrasound, and remote pulmonary pressure monitoring. In our opinion, clinicians must adopt a multiparametric approach offsetting the limitations of individual methods to formulate a management plan tailored to patients’ needs.

Congestion, marked by elevated cardiac filling pressures and their repercussions, is a contributing factor to morbidity and mortality in heart failure and critical illness. Relying on traditional methods for bedside evaluation often leads to inadequate decongestion and increased hospital readmissions. Point-of-care ultrasound (POCUS), particularly multi-organ POCUS, including the Venous Excess Ultrasound (VExUS), offers a promising approach in this scenario. VExUS enables the quantification of systemic venous congestion, aiding in fluid overload states by assessing inferior vena cava and venous Doppler waveforms. This comprehensive review delves into the latest developments in comprehending and evaluating congestion, shedding light on technical intricacies to enhance the effective application of VExUS. Recent studies emphasize the importance of evaluating signs of hemodynamic congestion before administering intravenous fluids, highlighting the concept of 'fluid tolerance'. Moreover, VExUS-guided decongestion significantly improves decongestion rates in acute decompensated heart failure patients with acute kidney injury. Newer studies also highlight the prognostic implications of VExUS in the general ICU cohorts not confining to cardiac surgery patients. However, performing VExUS without understanding technical pitfalls may lead to clinical errors. Technical considerations in performing VExUS include nuances related to inferior vena cava and internal jugular vein ultrasound and familiarity with Doppler principles, optimal settings, and artifacts. Additionally, local structural alterations such as those seen in liver and kidney disease impact Doppler waveforms, emphasizing the need for careful interpretation. Overall, VExUS presents a valuable tool for assessing congestion and guiding management, provided clinicians are familiar with its technical complexities and interpret findings judiciously.

Venous congestion, often associated with elevated right atrial pressure presents a clinical challenge due to its varied manifestations and potential organ damage. Recognizing the manifestations of venous congestion through bedside physical examination or laboratory tests can be challenging. Point-of-care ultrasound (POCUS) is emerging as a valuable bedside tool for assessing venous congestion, with the Venous Excess Ultrasound (VExUS) technique gaining prominence. VExUS facilitates non-invasive quantification of venous congestion, relying on measurements of the inferior vena cava (IVC) size and Doppler assessments of the hepatic vein (HV), portal vein (PV), and intrarenal vein, thereby providing real-time insights into hemodynamic status and guiding therapeutic interventions. The grading system outlined in VExUS aids in stratifying the severity of congestion. However, achieving proficiency in VExUS requires a comprehensive understanding of Doppler techniques and their clinical applications. This review article provides practical guidance on performing VExUS, encompassing equipment requirements, preparation, machine settings, and examination techniques for assessing the inferior vena cava (IVC), hepatic vein (HV), portal vein (PV), and intrarenal vein. Potential pitfalls and troubleshooting strategies are discussed to ensure accurate interpretation of Doppler waveforms.