POCUS and critical care echo

IVC and venous congestion (VExUS)

Reviewed Nov 2026·2 references
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The IVC estimates right atrial pressure in spontaneously breathing patients but predicts fluid responsiveness poorly, especially on the ventilator. A plethoric IVC with abnormal hepatic, portal and intrarenal Doppler (VExUS grade 2-3) signals venous congestion: stop fluids and consider decongestion.

At the bedside

Timed steps
  1. 1

    IVC

    Measure

    Subcostal long axis, 1-2 cm from RA junction. Spontaneous breathing: < 2.1 cm collapsing > 50% suggests low RAP (~3 mmHg); > 2.1 cm collapsing < 50% suggests high RAP (~15 mmHg).

  2. 2

    Ventilated

    Caution

    IVC distensibility > 18% may suggest fluid responsiveness in fully ventilated, passive patients with Vt ≥ 8 mL/kg; otherwise unreliable.

  3. 3

    VExUS

    If plethoric

    IVC ≥ 2 cm, then hepatic vein (S < D or reversed S), portal vein pulsatility (≥ 30% mild, ≥ 50% severe), intrarenal venous Doppler (biphasic or monophasic).

  4. 4

    VExUS

    Grade

    0: IVC < 2 cm. 1: plethoric, normal/mild patterns. 2: one severe pattern. 3: ≥ 2 severe patterns. Grade 3 associated with AKI after cardiac surgery.

  5. 5

    Congestion

    Act

    Stop fluids; diuretics or ultrafiltration if perfusion allows; treat RV failure.

Red flag · call your senior now
Plethoric IVC with hypotension: tamponade, tension pneumothorax, RV failure or PE.
Pitfall
Using a small IVC alone to give large volumes to a ventilated patient.
Pitfall
Raised intra-abdominal pressure compresses the IVC (false 'small IVC').
Pearl
Portal vein pulsatility is easy to obtain and changes quickly with decongestion.

References

  1. 1

    Via G, Hussain A, Wells M, et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014;27(7):683.e1-683.e33

  2. 2

    Beaubien-Souligny W, Rola P, Haycock K, et al. Quantifying systemic congestion with point-of-care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J. 2020;12(1):16

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