AB174. SOH24AB_135. Venous excess ultrasound waveforms can guide fluid balance management in the intensive care unit

Background: A 37-year-old man with known end-stage heart failure presented with a history of nausea, vomiting, abdominal discomfort, diarrhea, hypotension, and cellulitis. Broad spectrum antimicrobials and vasoactive medications were commenced, his diuretics were held, judicious intravenous fluid was prescribed, and he was admitted to the high dependency unit (HDU). It had been decided during a previous admission that he would not be a good candidate for invasive ventilation given his significant cardiac failure. The critical care team were consulted after 24 hours of treatment because of his progressive breathlessness.

Methods: A focused ultrasound in intensive care (FUSIC) scan was done. His cardiac chambers were well filled, dilated with poor biventricular contraction [his ejection fraction (EF) was known to be 35%]. His inferior vena cava (IVC) was dilated (>2 cm) and its diameter remained unchanged throughout the respiratory cycle both in the short and long axis views. The lung scans revealed widespread bilateral B-lines. Doppler ultrasound of the hepatic and portal veins was done.

Results: The hepatic veins revealed a doppler pattern consistent with reverse diastolic flow consistent with venous congestion. Intravenous fluids were stopped, and we advised the medical team to recommence the patient’s diuretic medications.

Conclusions: The venous excess ultrasound (VExUS) score is compiled using knowledge of the IVC, portal vein, hepatic vein, and renal vein doppler waveforms. Understanding abnormal venous doppler flow patterns can pinpoint when to transition the end-stage heart failure patient back to his regular diuretic treatment after successful treatment of a septic episode.

Keywords: Fluid responsiveness; heart failure; inferior vena cava (IVC); portal vein; venous excess ultra sound score