Fluid tolerance in septic shock: Femoral vein pulsatility versus VExUS score in a cross-sectional study
Article Sidebar
Main Article Content
Abstract
Background. Excessive fluid resuscitation in patients with septic shock is associated with acute organ injury and increased mortality. Accurate assessment of fluid tolerance is therefore essential. Right cardiac chamber fluid tolerance can be evaluated by estimating the right atrial pressure using central venous catheters, inferior vena cava (IVC) measurements, Venous Excess Ultrasound (VExUS) scores and femoral vein pulsatility (FVP).
Objectives. To assess the correlation between FVP and VExUS score in evaluating fluid intolerance and venous congestion in patients with septic shock; the correlation of FVP and VExUS score with central venous pressure (CVP); and to evaluate the effect of positive pressure ventilation on the relationship between FVP and VExUS score.
Methods. In this observational cross-sectional study, 80 participants were assessed for fluid tolerance using VExUS scores and FVP. CVP, maximum and minimum IVC diameters and IVC dynamicity were regarded as the gold standard and used as reference.
Results. FVP showed moderate agreement with VExUS score (Kappa=0.55; p<0.001). Both FVP and VExUS score demonstrated the ability to predict CVP values ≥17 cmH2O with overall accuracies of 70% and 77.5%, respectively (p<0.001). A CVP ≥17.5 cmH2O predicted severely congested femoral veins with a sensitivity of 70% and specificity of 90%, whereas a CVP ≥18.5 cmH2O predicted VExUS grade 3 with a sensitivity of 66.7% and specificity of 83.3%. Maximum IVC diameter accurately predicted abnormal femoral vein Doppler findings, with an overall accuracy of 82.5%.
Conclusion. A pulsatile femoral vein pattern indicates fluid intolerance in patients with septic shock, providing an additional marker for assessing fluid status. Doppler assessment of the femoral vein offers advantages of easier anatomical accessibility and a shorter learning curve compared with other methods.
Article Details
Issue
Section
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Authors retain copyright and grant the journal right of first publication.
How to Cite
References
1. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021;47(11):1181-1247. https:// doi.org/10.1007/s00134-021-06506-y
2. Galindo P, Gasca C, Argaiz ER, Koratala A. Point of care venous Doppler ultrasound: Exploring the missing piece of bedside hemodynamic assessment. World J Crit Care Med 2021;10(6):310- 322. https://doi.org/10.5492/wjccm.v10.i6.310
3. Joseph A, Petit M, Vignon P, Vieillard-Baron A. Fluid responsiveness and venous congestion: Unraveling the nuances of fluid status. Crit Care 2024;28(1):140. https://doi.org/10.1186/s13054- 024-04930-2
4. Melo RH, dos Santos MHC, da Silva Ramos FJ. Beyond fluid responsiveness: The concept of fluid tolerance and its potential implication in hemodynamic management. Crit Care Sci 2023;35(2):226-229. https://doi.org/10.5935/2965-2774.20230012-en
5. Chen Y, Shlofmitz E, Khalid N, et al. Right heart catheterization – Related complications: A review of the literature and best practices. Cardiol Rev 2020;28(1):36-41. https://doi.org/10.1097/ crd.0000000000000270
6. Rola P, Haycock K, Spiegel R. What every intensivist should know about the IVC. J Crit Care 2024;80:154455. https://doi.org/10.1016/j.jcrc.2023.154455
7. Beaubien-Souligny W, Rola P, Haycock K, et al. Quantifying systemic congestion with point-of- care ultrasound: Development of the venous excess ultrasound grading system. Ultrasound J 2020;12:16. https://doi.org/10.1186/s13089-020-00163-w
8. Longino A, Martin K, Leyba K, et al. Correlation between the VExUS score and right atrial pressure: A pilot prospective observational study. Crit Care 2023;27(1):205. https://doi. org/10.1186/s13054-023-04471-0
9. Denault AY, Aldred MP, Hammoud A, et al. Doppler interrogation of the femoral vein in the critically ill patient: The fastest potential acoustic window to diagnose right ventricular dysfunction? Crit Care Explor 2020;2(10):209. https://doi.org/10.1097/cce.0000000000000209
10. Calderone A, Hammoud A, Jarry S, Denault A, Couture EJ. Femoral vein pulsatility: What does it mean? J Cardiothorac Vasc Anesth 2021;35(8):2521-2527. https://doi.org/10.1053/j. jvca.2021.03.027
11. Dandu C, Dobesh K, Grewel A, Natour A, Kabbani L, Ahsan S. Lower extremity venous pulsatility is associated with elevated pulmonary artery pressures and tricuspid regurgitation. J Vasc Surg Venous Lymphat Disord 2023;11(2):460. https://doi.org/10.1016/j.jvsv.2022.12.041
12. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315(8):801-810. https://doi.org/10.1001/ jama.2016.0287
13. Bhardwaj V, Rola P, Denault A, Vikneswaran G, Spiegel R. Femoral vein pulsatility: A simple tool for venous congestion assessment. Ultrasound J 2023;15:24. https://doi.org/10.1186/s13089- 023-00321-w
14. Gupta B, Ahluwalia P, Gupta A, Ranjan N, Kakkar K, Aneja P. Utility of VExUS score in the peri- operative care unit, intensive care unit, and emergency setting – A systematic review. Indian J Anaesth 2023;67(Suppl 4):S218-S226. https://doi.org/10.4103/ija.ija_475_23
15. Menéndez-Suso JJ, Rodríguez-Álvarez D, Sánchez-Martín M. Feasibility and utility of the venous excess ultrasound score to detect and grade central venous pressure elevation in critically ill children. J Ultrasound Med 2023;42(1):211-220. https://doi.org/10.1002/jum.16057
16. Andrei S, Bahr PA, Alissant M, et al. Pulsatile femoral vein Doppler pattern is a parameter of venous congestion in ICU patients. J Cardiothorac Vasc Anesth 2023;38(6):1361-1368. https:// doi.org/10.1053/j.jvca.2023.04.028
17. Cozcolluela MR, Sarría L, Sanz L, et al. Correlation of central venous pressure with Doppler waveform of the common femoral veins. J Ultrasound Med 2000;19(8):587-592. https://doi. org/10.7863/jum.2000.19.8.587
18. Alimoğlu E, Erden A, Gürsel K, Olçer T. Correlation of right atrial pressure and blood flow velocities in the common femoral vein obtained by duplex Doppler sonography. J Clin Ultrasound 2001;29(2):87-91. https://doi.org/10.1002/1097-0096(200102)29:2%3C87::aid- jcu1003%3E3.0.co;2-1
19. Muñoz O, Ferrusquía-Acosta J, Serna-Patiño LM, Cárdenas A. Diagnostic methods of portal hypertension. Revi Colomb Gastroenterol 2021;36(2):218-226. https://doi. org/10.22516/25007440.692