VExUS predicts well in cardiac patients and poorly in everyone else

Design

systematic review and meta-analysis of 32 diagnostic and prognostic studies, four databases searched to May 2025

Population

3,142 patients across cardiac and general critically ill populations

Primary outcome

diagnostic accuracy for raised central venous and right atrial pressure; association of VExUS grade with acute kidney injury and mortality

Effect

sensitivity 78-95%, specificity 80-90%; cardiac patients VExUS 2+ for AKI OR 4.44 (2.34-8.43) and mortality 3.17 (1.30-7.75); critically ill patients AKI 1.45 (0.70-2.99), mortality 1.25 (0.77-2.03)

The venous excess ultrasound grading system has spread quickly as a bedside way to judge venous congestion and guide fluid decisions. This systematic review searched four databases to May 2025 and found 32 studies covering 3,142 patients — six diagnostic, 22 prognostic, four both.

Diagnostic studies could not be pooled, but individually suggested moderate to good accuracy for detecting raised central venous and right atrial pressure, with sensitivity 78-95% and specificity 80-90%. The prognostic picture split by population. In cardiac patients, a VExUS grade of 2 or more was associated with acute kidney injury (OR 4.44, 95% CI 2.34-8.43, moderate certainty) and mortality (OR 3.17, 1.30-7.75, low certainty). In general critically ill patients, neither association held: acute kidney injury OR 1.45 (0.70-2.99, very low certainty) and mortality 1.25 (0.77-2.03).

That split is the finding, and it is easy to lose. Congestion measured at the hepatic, portal and renal veins carries prognostic weight where right-sided pressure is the dominant problem, which describes cardiac patients. In a general intensive care population, where shock is distributive, septic or mixed, the same grade means different things in different patients. Use VExUS to answer whether a patient is congested, and be sceptical of it as a general prognostic marker or a fluid-stopping rule.

• Use VExUS to assess congestion, not to prognosticate in undifferentiated critical illness
• The evidence is strongest in cardiac patients — that is where grade 2 or more carried weight
• Certainty of evidence was rated low or very low for most prognostic outcomes
• Combine with clinical assessment and echocardiography rather than treating a grade as a decision
• Nothing here shows that acting on VExUS improves outcome; no interventional trial exists

The statistics, in plain English

An odds ratio of 4.44 (2.34-8.43) in cardiac patients is a substantial association; the 1.45 (0.70-2.99) in critically ill patients crosses 1.0 and so shows no detectable association rather than proof of none. The certainty ratings matter more than the point estimates here: 'very low certainty' means further research is very likely to change the estimate. Diagnostic accuracy figures come from individual studies that could not be pooled, so the ranges quoted are the spread across studies, not a synthesised estimate with a confidence interval.

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