One thought on “Venous #POCUS Case Discussion. #VEXUS #FOAMed #FOAMcc”

1. 

   August 2, 2019 at 11:36 pm

   Aman Thind

   Hi Philippe! I’ve recently started reading your blog and been enjoying it a lot. It’s great to see cardiorenal syndrome getting the attention it deserves. This case taught us so much.

   – ‘Fluid responsiveness’ and ‘fluid intolerance’ are not mutually exclusive (especially in advanced stages of heart failure). I first learned this while reading Dr. Daniel De Backer’s textbook. It was a total lightbulb moment. His reference was to the left heart – there could be a situation where increased intravascular volume causes increased LV output while also elevating LA pressure. Your case highlights the same principle for the right heart. The patient had ultrasonographic evidence of renal congestion. Yet, fluid administration improved renal function, plausibly because the increase in cardiac output (“forward flow”) superseded the potential worsening of renal congestion – thereby improving renal perfusion. What helped in this case was other venous indices (IVC and PV) your familiarity with the patient. Trends always help.

   – Also makes me wonder that perhaps in this patient population, equal attention should be made to doppler evaluation of cardiac output (via LVOT VTI). More advanced the heart failure, narrower would be the safe zone on the Frank-Starling curve. Overdiuresis would cause WRF due to reduction in cardiac output (leftward shift from the safe zone on the curve). This change can be detected by trending cardiac output. Again, a single reading of cardiac output (unless extremely low) may not be helpful; but if the baseline is known, detection of a significant drop with diuresis may have diagnostic value.

   – Aman.

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