Abstract
BackgroundOrgan congestion is a mediator of adverse outcomes in critically ill patients. Point-Of-Care ultrasound (POCUS) is widely available and could enable clinicians to detect signs of venous congestion at the bedside. The aim of this study was to develop several grading system prototypes using POCUS and to determine their respective ability to predict acute kidney injury (AKI) after cardiac surgery. This is a post-hoc analysis of a single-center prospective study in 145 patients undergoing cardiac surgery for which repeated daily measurements of hepatic, portal, intra-renal vein Doppler and inferior vena cava (IVC) ultrasound were performed during the first 72 h after surgery. Five prototypes of venous excess ultrasound (VExUS) grading system combining multiple ultrasound markers were developed.ResultsThe association between each score and AKI was assessed using time-dependant Cox models as well as conventional performance measures of diagnostic testing. A total of 706 ultrasound assessments were analyzed. We found that defining severe venous congestion as the presence of severe flow abnormalities in multiple Doppler patterns with a dilated IVC (≥ 2 cm) showed the strongest association with the development of subsequent AKI compared with other combinations (HR: 3.69 CI 1.65–8.24 p = 0.001). The association remained significant after adjustment for baseline risk of AKI and vasopressor/inotropic support (HR: 2.82 CI 1.21–6.55 p = 0.02). Furthermore, this severe VExUS grade offered a useful positive likelihood ratio (+LR: 6.37 CI 2.19–18.50) when detected at ICU admission, which outperformed central venous pressure measurements.ConclusionsThe combination of multiple POCUS markers may identify clinically significant venous congestion.
Highlights
Organ congestion is a mediator of adverse outcomes in critically ill patients
In this work, we aimed to investigate the performance of different venous congestion grading systems based on ultrasound markers to predict acute kidney injury (AKI) after cardiac surgery
Proportional hazard regression models (Cox) with venous excess ultrasound (VExUS) grading systems considered as time varying covariates (i.e., VExUS grade at day 0 is used to predict acute kidney injury (AKI) at day 1, VExUS grade at day 1 is used for AKI at day 2 and so on)
Summary
Organ congestion is a mediator of adverse outcomes in critically ill patients. Point-Of-Care ultrasound (POCUS) is widely available and could enable clinicians to detect signs of venous congestion at the bedside. The aim of this study was to develop several grading system prototypes using POCUS and to determine their respective ability to predict acute kidney injury (AKI) after cardiac surgery This is a post-hoc analysis of a single-center prospective study in 145 patients undergoing cardiac surgery for which repeated daily measurements of hepatic, portal, intra-renal vein Doppler and inferior vena cava (IVC) ultrasound were performed during the first 72 h after surgery. While higher CVP has been associated with complications in multiple settings [10,11,12], it remains unclear what level of CVP is deleterious and may be considered a trigger for intervention [13] Other metrics such as cumulative fluid balance, weight variations and physical examination for peripheral edema, each have important limitations and may not be proportional to systemic venous pressure [14,15,16]
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