Today, we discuss the VEXUS Score. One of the big philosophical mistakes of early EMCrit was my approach to fluids in sepsis. It is no excuse that I was in good company–as in most of the intensivists in the US. I've come to my senses in the past 8 years or so and now I am actively fighting to avoid the drowning of our patients. One of the stalwarts in that fight is my buddy Phillipe Rola. He is an intensivist in Montreal, EMCrit team member, and creator of the Thinking Critical Care Blog.
He, along with Rory Spiegel and Korbin Haycock, has created the VEXUS score to evaluate your patient for fluid overload.
VEXUS Article
VEXUS Score
Hepatic Vein
Look at the IVC in the sub-xiphoid
Phased Array Probe may be easiest, but Curvilinear works as well
S wave should be larger than D wave
TR may be a confounder
S just after QRS if you have ECG leads
Portal Vein
Mid-Ax Line on Right Side with probe longitiduinal or R Costal Margin
Use curvilinear
Flow should move towards probe (red)
Normal is continuous flow
If it becomes pulsatile, there is backpressure
If it drops below baseline that is bad
PF <=0.5 (same thing as resistive index)
may be abnormal in pts with low BMI
Renal Artery
Curvilinear with Abd preset
Use color doppler to find vessels
Pick a vessel and look at the PW wave
RRI
0.55-0.7 is normal
Approaches 1 when there is an absence of diastolic flow
IRVF
Look for vein in parenchyma
Katie Wiskar Tutorial
Venous Excess Chapter from Phillipe's Book
More from Phillipe on this Topic
- EMCrit Podcast 240- Renal Compartment Syndrome It's all about the Venous Side and We've Been Fracking it up for Years
- Posts on Thinking CC
- Vexus Lite
- VEXUS Mini-Tutorial with Live Vid of a Scan
Literature
Resus Crisis Manual
Additional New Information
More on EMCrit
- EMCrit Podcast 175 – Fluid Tolerance and Follow-Up on the Fluids in Sepsis Panel with Phillipe Rola(Opens in a new browser tab)
- EMCrit 286 – The Venous Side Matters Too with Phil Rola(Opens in a new browser tab)
Additional Resources
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- EMCrit 371 – Iodinated Contrast Issues: Part 2 – Contrast Reactions - March 24, 2024
- EMCrit Wee – Zentensivism with Matt Siuba - March 15, 2024
- EMCrit 370 – Extracorporeal Therapies for Toxicology & Poisoning #ExTRIP #NephMadness - March 8, 2024
Love this concept. Wonder, could this be applied to patients with cirrhosis, (either with or without portal HTN)?
absolutely – in fact the VEXUS was partly designed to eliminate false positives which can happen by looking at PV alone
Great episode. Should we expect vasopressors to impact our VEXUS score or should we change how we interpret it if a patient is on pressors?
Thanks! If there is recruitable volume, vasopressors likely will. No need to change how you interpret, the pressure the organs see is what is there, regardless of the etiology. Validation paters coming…
Great post and I love the approach which makes physiological sense. I’m South Africa and would like to get a copy of Philippe’s book which looks amazing but I can’t get it from either amazon or iTunes. Any other way I could preferably purchase a copy of the book?
Wix ships internationally!
https://ccusinstitute.wixsite.com/ccus/product-page/bedside-ultrasound-a-primer-for-clinical-integration-2nd-edition
I love the concept for volume evaluation all together. But i don‘t really understand the concept in sepsis. Our Problem in sepsis normally is not intravascular fluid but capillary leak, meaning extravasation of fluids. Those fluids won‘t be measured by that score or am i getting something wrong? But volume overload is so common and i‘m constantly using POCUS for volume evaluation, love to have a score for it 🙂 thanks a lot!
think the reason you are having trouble is that you probably already practice good medicine. In many places in North AMerica, they give so much fluid that it overwhelms the rate of extrav
Thankes 🙂
Thanks 🙂
Thanks so much for this Podcast with THE Phillipe Rola. Learned so much from these VExUS Pioneers.
I am Jose Luis do Pico. I´m from Necochea, Argentina. I´m medical doctor, I work in Critical Care Medicine for 43 years and I love US in critical care patients. About the score it´s very interesting but I have doubts about de VCI diameter, there are many doubts about this, especially in ventilated patients…..I use the rest venous patterns, I agreed with that. Gratulations for your work and sorry by my English, it´s very bad.
Best regards
your english is very good and your comets better