Dear Editor,
I read with great interest the recent article titled “Unlocking the Potential of VExUS in Assessing Venous Congestion: The Art of Doing it Right,” which critically examines the utility of venous excess ultrasound (VExUS) scores in assessing venous congestion. The article evaluates venous congestion across different clinical scenarios and patient populations, including those with heart failure and in critical illness [1]. While the article admirably underscores the importance of VExUS in guiding fluid management and predicting outcomes, I am particularly interested in delving deeper into certain caveats and limitations necessary to enhance its clinical applicability.
Technical Challenges and Methodological Considerations
The article rightly highlights the technical intricacies involved in performing VExUS assessments, particularly in interpreting inferior vena cava (IVC) and internal jugular vein ultrasound, along with Doppler evaluations. However, it is crucial to acknowledge the complexities associated with using IVC diameter alone to estimate right atrial pressure, especially in mechanically ventilated patients where such correlations may not hold uniformly. Factors such as anatomical variations, abdominal compliance, and intra-abdominal pressure dynamics can significantly influence IVC measurements, necessitating a nuanced approach that includes comprehensive visualization techniques and possibly integrating alternative modalities like internal jugular vein dynamics to mitigate potential inaccuracies [2].
Clinical Implications in Hepatic and Renal Pathophysiology
The article appropriately discusses how local structural changes in liver and kidney diseases can impact Doppler waveforms, thereby complicating the interpretation of VExUS findings. It is imperative to recognize that conditions such as liver cirrhosis or acute kidney injury can markedly alter venous hemodynamics, potentially confounding the reliability of traditional ultrasound parameters [3]. In such clinical scenarios, the integration of supplementary diagnostic tools and clinical judgment becomes indispensable to augment VExUS assessments and ensure judicious therapeutic decision-making [4].
Prognostic Insights and Methodological Rigor
While acknowledging the established prognostic value of VExUS in cardiac surgery settings, the article rightly underscores the variability in its predictive accuracy across broader intensive care unit (ICU) populations. Discussions around the correlation between VExUS scores and clinical outcomes such as acute kidney injury or mortality highlight existing inconsistencies in the literature. For instance, while some studies report significant associations between higher VExUS grades and adverse outcomes, others suggest limited predictive utility in heterogeneous ICU cohorts [5]. This variability underscores the urgent need for methodologically rigorous multicenter studies with robust sample sizes to validate the prognostic efficacy of VExUS across diverse patient profiles and clinical contexts.
Optimizing Fluid Management Strategies and Patient-Centered Care
The article’s introduction of the concept of “fluid tolerance” and emphasis on assessing hemodynamic congestion before administering fluids reflect a prudent approach aligned with contemporary patient-centered care principles. However, it is essential to underscore the complexity of fluid responsiveness assessment in critically ill patients, where individualized hemodynamic profiles and therapeutic goals necessitate a nuanced approach. Balancing the risks of fluid overload against the imperative to maintain adequate tissue perfusion underscores the critical role of integrating comprehensive clinical assessment with advanced diagnostic tools like VExUS to optimize fluid management strategies effectively [6].
Future Directions and Recommendations for Clinical Implementation
To enhance the clinical utility of VExUS, concerted efforts are warranted to standardize training protocols for clinicians and refine measurement techniques to mitigate interobserver variability. Moreover, expanding research initiatives should prioritize investigating the role of VExUS in specific patient cohorts, including those with complex hepatic or renal pathophysiology, to elucidate its utility beyond traditional ICU settings. Multicenter collaborations are essential to establish robust evidence supporting the broader applicability of VExUS in predicting clinical outcomes and guiding tailored therapeutic interventions.
In conclusion, while recognizing the potential of VExUS as a valuable tool in assessing venous congestion and optimizing fluid management in critically ill patients, ongoing scientific rigor and methodological refinement are imperative to enhance its clinical validity and utility. As a practitioner committed to advancing nephrological care, I advocate for continued interdisciplinary collaboration and evidence-based research to maximize the impact of VExUS in improving patient outcomes.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
This study was not supported by any sponsor or funder.
Author Contributions
R.H.P. and P.G.Z.T. conceived and designed the study, drafted the initial manuscript, and performed critical revisions. C.M.P., V.B.G., R.S.A., T.D.M., and U.A.P.F. reviewed and edited the manuscript. All authors approved the final version.
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