A56-11 Venus Excess Ultrasound (vexus) Beyond the Ivc: Rethinking Fluid Tolerance and Venous Congestion in the Critically Ill

Abstract Rationale In critical care, fluid management often feels like a balancing act. Too little resuscitation risks poor perfusion, while too much fluid quietly raises venous pressures and sets the stage for organ failure. For decades, clinicians have leaned on central venous pressure or IVC measurements, but these static metrics often fail to capture what really drives harm hidden venous congestion.The Venous Excess Ultrasound (VExUS) score was developed to address that gap. By integrating IVC size with Doppler waveforms from the hepatic, portal, and intrarenal veins, VExUS offers a dynamic, bedside view of systemic congestion. The concept is intuitive: if we can visualize venous hypertension before it triggers kidney or hepatic injury, we can intervene earlier. Initial studies, especially after cardiac surgery, showed strong links between higher VExUS grades and acute kidney injury (AKI). Yet, how well this tool applies to the broader ICU population remains an open question worth exploring. Methods We conducted a systematic review following PRISMA and SWiM guidelines (PROSPERO CRD42023421034). PubMed, Embase, and Cochrane databases were searched through May 2025 for studies evaluating adult ICU or perioperative patients using the full VExUS protocol. Data extraction included study design, patient characteristics, VExUS grading, and outcomes such as AKI, renal replacement therapy, and mortality. Study quality was assessed using the Newcastle-Ottawa scale, and pooled effect sizes were calculated via a random-effects model when feasible. Results Fifteen observational studies encompassing roughly 1,000 patients met inclusion criteria. Across pooled analyses, a VExUS grade ≥ 2 was associated with AKI (pooled OR 2.63, 95% CI 1.06-6.54; p = 0.04) but not with mortality (Annals of Intensive Care, 2025; The Ultrasound Journal, 2025). In unselected ICU populations, elevated VExUS grades were seen in about 18-20% of patients. Inter-observer reliability was strong (ICC ≈ 0.83) when standardized Doppler protocols were used (Critical Care, 2024). Several studies also noted that VExUS identified venous congestion even when IVC or central venous pressure readings appeared normal. Conclusion VExUS represents a shift from assessing fluid “status” to understanding fluid “tolerance.” By synthesizing Doppler information from multiple venous territories, clinicians can recognize early congestion before overt organ injury develops. The evidence so far supports its diagnostic promise, but interventional trials are still needed to determine whether VExUS-guided decongestion strategies can reduce AKI or improve outcomes. As critical care moves toward precision resuscitation, VExUS stands out as a practical and physiologic tool that bridges imaging, hemodynamics, and patient-specific care. This abstract is funded by: None