Abstract
Introduction
The venous excess ultrasonography (VExUS) score is a new method of scoring systemic congestion based on inferior vena cava (IVC) dilatation and pulsed-wave Doppler (PW-Doppler) morphology of hepatic, portal and intra-renal veins. It has been proposed and validated as a score to evaluate systemic congestion, however its role as a prognostic marker in sepsis patients is yet to be studied.
Objectives
To evaluate the role of VExUS score in predicting mortality and its relationship with length of stay (LOS) in ICU, duration of mechanical ventilation (MV) and the need for renal replacement therapy (RRT) in sepsis patients.
Materials and methods
All patients admitted with sepsis and septic shock were enrolled. APACHE IV and SOFA scores were calculated within the first 24 hours of admission in ICU. Serum nTproBNP, Serum lactates, serum procalcitonin and VExUS score were calculated for each patient on the day of admission and after 72 hours of stay. Daily average fluid balance and cumulative fluid balance at 72 hours were also calculated. All the study patients were followed up for 4 weeks from the day of admission or till their stay in ICU (whichever is shorter) recording the incidence of poor outcomes like LOS in ICU, duration of MV, need for RRT and ICU mortality.
Results
A total of 143 participants participated in the study. 99 patients in the study were discharged (69.23%), while 44 patients in the study (30.77%) died. 38 patients (26.57%) showed a reduction while 24 patients (16.78%) showed an increase in VExUS score on day 3 versus day 1. 69 patients in the study did not require MV, while 74 patients were managed on MV. The mean duration of MV(8.11 +/– 4.34 vs 11.49 +/– 4.68) and LOS in ICU (11.55 +/– 7.60 vs 13.46 +/– 7.38) were both significantly higher in the patients with increase in VExUS score, versus the patients with decrease in VExUS score (p < 0.05). 64 patients (44.76%) required RRT. RRT requirement in the patients with increased VExUS score on day 3 (87.50%) was significantly greater than those with decreased score (p < 0.05). Similarly, mortality in the patients with increased VExUS score (79.17%) was significantly greater (p < 0.05). VExUS score on day 1 was noted to have AUC of 0.74 (95% CI: 0.65 to 0.83, p < 0.05). This shows that VExUS score can be considered a strong predictor of death in sepsis patients.
Conclusion
VExUS score was able to predict RRT requirement, longer MV duration and longer ICU stay duration. VExUS was found to be a strong predictor of mortality in sepsis cases. Hence, the VExUS scoring system demonstrates promise for early identification of critically ill septic patients and may further aid in risk stratifying these patients upon arrival in the emergency department. Future studies with multicenter study design and larger sample size will help in validating our study findings.
References
- 1.Sakr Y, Rubatto Birri PN, Kotfis K, Nanchal R, Shah B, Kluge S, et al. Higher fluid balance increases the risk of death from sepsis: results from a large international audit. Crit Care Med. 2017;45:386–94. doi: 10.1097/CCM.0000000000002189. [DOI] [PubMed] [Google Scholar]
- 2.Beaubien-Souligny W, Rola P, Haycock K. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J. 2020;12:16. doi: 10.1186/s13089-020-00163-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Kelm DJ, Perrin JT, Cartin-Ceba R, Gajic O, Schenck L, Kennedy CC. Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death. Shock. 2015;43(1):68–73. doi: 10.1097/SHK.0000000000000268. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Zhang L, Xu F, Li S, Zheng X, Zheng S, Liu H, Lyu J, Yin H. Influence of fluid balance on the prognosis of patients with sepsis. BMC Anesthesiol. 2021;21(1):269. doi: 10.1186/s12871-021-01489-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Rolston D, Li T, Huang H, Johnson A, van Loveren K, Kearney E, et al. A higher initial VExUS score is associated with inferior outcomes in septic emergency department patients. Ann Emerg Med [Internet] 2021;78(4):S82. [Google Scholar]