Seeing beneath the surface:Harnessing point-of-care ultrasound for internal jugular vein evaluation

Point-of-care ultrasound(POCUS)of the internal jugular vein(IJV)offers a noninvasive means of estimating right atrial pressure(RAP),especially in cases where the inferior vena cava is inaccessible or unreliable due to conditions such as liver disease or abdominal surgery.While many clinicians are familiar with visually assessing jugular venous pressure through the internal jugular vein,this method lacks sensitivity.The utilization of POCUS significantly enhances the visualization of the vein,leading to a more accurate identification.It has been demonstrated that combining IJV POCUS with physical examination enhances the specificity of RAP estimation.This review aims to provide a comprehensive summary of the various sonographic techniques available for estimating RAP from the internal jugular vein,drawing upon existing data.

Point-of-care ultrasonography in cirrhosis-related acute kidney injury:How I do it

Discerning the etiology of acute kidney injury(AKI)in cirrhotic patients remains a formidable challenge due to diverse and overlapping causes.The conventional approach of empiric albumin administration for suspected volume depletion may inadvertently lead to fluid overload.In the recent past,point-of-care ultrasonography(POCUS)has emerged as a valuable adjunct to clinical assessment,offering advantages in terms of diagnostic accuracy,rapidity,cost-effectiveness,and patient satisfaction.This review provides insights into the strategic use of POCUS in evaluating cirrhotic patients with AKI.The review distinguishes basic and advanced POCUS,emphasizing a 5-point basic POCUS protocol for efficient assessment.This protocol includes evaluations of the kidneys and urinary bladder for obstructive nephropathy,lung ultrasound for detecting extravascular lung water,inferior vena cava(IVC)ultrasound for estimating right atrial pressure,internal jugular vein ultrasound as an alternative to IVC assessment,and focused cardiac ultrasound for assessing left ventricular(LV)systolic function and identifying potential causes of a plethoric IVC.Advanced POCUS delves into additional Doppler parameters,including stroke volume and cardiac output,LV filling pressures and venous congestion assessment to diagnose or prevent iatrogenic fluid overload.POCUS,when employed judiciously,enhances the diagnostic precision in evaluating AKI in cirrhotic patients,guiding appropriate therapeutic interventions,and minimizing the risk of fluid-related complications.

Predictors of mortality after transjugular portosystemic shunt

AIM:To investigate if echocardiographic and hemodynamic determinations obtained at the time of transjugular intrahepatic portosystemic shunt(TIPS)can provide prognostic information that will enhance risk stratification of patients.METHODS:We reviewed medical records of 467 patients who underwent TIPS between July 2003 and December 2011 at our institution.We recorded information regarding patient demographics,underlying liver disease,indication for TIPS,baseline laboratory values,hemodynamic determinations at the time of TIPS,and echocardiographic measurements both before and after TIPS.We recorded patient comorbidities that may affect hemodynamic and echocardiographic determinations.We also calculated Model for Endstage Liver Disease(MELD)score and Child Turcotte Pugh(CTP)class.The following pre-and post-TIPS echocardiographic determinations were recorded:Left ventricular ejection fraction,right ventricular(RV)systolic pressure,subjective RV dilation,and subjective RV function.We recorded the following hemodynamic measurements:Right atrial(RA)pressure before and after TIPS,inferior vena cava pressure before and after TIPS,free hepatic vein pressure,portal vein pressure before and after TIPS,and hepatic venous pressure gradient(HVPG).RESULTS:We reviewed 418 patients with portal hypertension undergoing TIPS.RA pressure increased by a mean ± SD of 4.8 ± 3.9 mmH g(P < 0.001),HVPG decreased by 6.8 ± 3.5 mmH g(P < 0.001).In multivariate linear regression analysis,a higher MELD score,lower platelet count,splenectomy and a higher portal vein pressure were independent predictors of higher RA pressure(R = 0.55).Three variables predicted 3-mo mortality after TIPS in a multivariate analysis:Age,MELD score,and CTP grade C.Change in the RA pressure after TIPS predicted long-term mortality(per 1 mm Hg change,HR = 1.03,95%CI:1.01-1.06,P < 0.012).CONCLUSION:RA pressure increased immediately after TIPS particularly in patients with worse liver function,portal hypertension,emergent TIPS placement and history of splenectomy.The increase in RA pressure after TIPS was associated with increased mortality.Age,splenectomy,MELD score and CTP grade were independent predictors of long-term mortality after TIPS.