POCUS Evaluation Of Venous Congestion From Dr. Phillipe Rola With Additional Resources On Pulmonary Congestion And Pulmonary Hypertension

Every Emergency Medicine, Critical Care, and Hospital Medicine specialist needs to master the material that Dr. Rola’s blog, Thinking Critical Care, has included on the use of POCUS to determine fluid status in the critically ill patient.

And every paramedic with access to point of care ultrasound also needs to master the information Dr. Rola shares.

For both of the above groups, this knowledge will undoubtedly save lives!

I first heard Critical Care Specialist Dr. Philippe Rola lecture on Dr. Weingart’s EMCrit Podcast 240 EMCrit Podcast 240 – Renal Compartment Syndrome & It’s all about the Venous Side and We’ve Been Fracking it up for Years* February 10, 2019 by Dr. Scott Weingart of the awesome EMCrit site. And this awesome podcast is the place to start on this subject.

* The title was initially confusing to me because the podcast is actually about the treatment of a patient thought initially to have intractable end-stage hepatorenal syndrome and end-stage heart failure.  When Dr. Rola was consulted about the patient, he successfully treated the patient by carefully determining the patient’s optimal fluid balance using bedside POCUS of the portal vein.

The patient above did have a renal compartment syndrome from venous congestion – hence the podcast title. Dr. Weingart reminds us that kidney perfusion pressure is not the mean arterial pressure (MAP)  Rather kidney perfusion pressure is actually the mean arterial pressure minus the venous pressure.

So, in some cases, over hydration can lead to decreased kidney perfusion and increased serum creatinine by increasing the kidney’s venous pressure to a greater degree then it increases the kidney’s arterial pressure.

When acute kidney injury is detected by an increase of serum creatinine in a patient who is hypotensive or borderline hypotension it is natural to assume  that that the cause is pre-renal. And, of course, most of the time it is and increasing perfusion by a fluid bolus or pressor support to increase the arterial pressure works to improve kidney function [after catheterizing the bladder to rule out obstructive acute renal injury]. In both maneuvers the goal is to increase the MAP and increase kidney perfusion.

But the above is strategy does not always work.

And Dr. Rola’s textbook and awesome posts referenced below help us to decide how to address acute kidney injury manifested by an acute rise in creatinine.


(1)  EMCrit Podcast 240 – Renal Compartment Syndrome & It’s all about the Venous Side and We’ve Been Fracking it up for Years – February 10, 2019 by Dr. Scott Weingart of EMCrit. In the podcast Dr. Weingart interviews intensivist Dr. Phillipe Rola of Thinking Critical Care.

(2) Chapter 6 Special Skills: Venous Congestion [PDF] Dr. Phillippe Rola with co-authors Dr. Korbin Haycock & Dr. Rory Spiegel from the book Bedside Ultrasound: A Primer for Clinical Integration, 2nd edition* V.2019.

*This link is to the Amazon page for the book. And this link is to purchase the e-book [This ebook is only available at iTunes and I don’t have an Apple device – will provide link when I can]. [Please note, neither are affiliate links. I just included them for readers convenience.]

Here is a paragraph from the Amazon purchase page for the above book:

Not simply another “how-to” POCUS book, this is meant to take the novice or intermediate bedside sonographer-clinician on teaching rounds with a POCUS and resucitation veteran, providing the integration of imaging with clinical management. Aimed for physicians taking care of acutely ill patients and wanting to take their game to another level, not just in terms of POCUS skills, but more importantly in how to truly embrace the next phase in clinical assessment, one where all systems are co-examined with bedside imaging. Using a clinical syndrome-based approach, this will help readers reframe their clinical thinking from a new and especially physiological perspective. A must-read for anyone taking care of sick patients. Dr. Scott Weingart*, founder of EMCrit, says: “The team at EMCrit specializes in taking difficult clinical ideas and logistically translating them to bedside use; this amazing book has taken the same path. Dr. Philippe Rola is a consummate and practical critical care clinician. He has crafted a book that radiates with this clinical acumen. It is stripped down to solely the clinically relevant essential knowledge to teach you how to use Point-of-Care Ultrasound at the bedside of the acutely or critically ill patient to answer vital questions. It is well worth mastering all of the techniques in this guide as each will add to your capabilities of caring for your patients on the wards, in the ED or in the ICU.” Also see foreword by Dr. Josh Farkas!*

* The fact that this book is endorsed by Drs. Weingart and  Farkas, two of the very best medical educators on the internet, tells you all you need to know about the book. I bought it.

(3) Excerpts From “A Simplified Ultrasound Comet Tail Grading Scoring to Assess Pulmonary Congestion in Patients with Heart Failure”
Posted on February 21, 2019 by Tom Wade MD

The above post has direct links to the full article and to the accompanying teaching videos which need to be reviewed.

(4) Venous Congestion from different Clinical Standpoints, May 13, 2019 by Dr. Phillipe Rola of Thinking Critical Care.

Be sure to listen to the podcast contained in the above link and to carefully review the accompanying show notes.

(5) Another interesting question from @JCHCheung!, April 25, 2019 by Dr. Phillipe Rola of Thinking Critical Care.

(6) Venous Congestion: A Reader’s Questions, April 21, 2019 Dr. Phillipe Rola of Thinking Critical Care.

(7) Relational Time Patterns: An EKG for Sepsis? A deeper look into the StormTracker with @patientstormdoc!, April 19, 2019, by Dr. Phillipe Rola of Thinking Critical Care.

(8) My friend, the IVC, March 13, 2019, by Dr. Phillipe Rola of Thinking Critical Care.

Here is the direct link to Dr. Rolla’s slide presentation.

But the best way to get the most out of Dr. Rolla’s slide presentation is to open the slides above in a separate window and to go to Dr. Rolla’s post, My Friend, the IVC. That link is to the audio that accompanies the slides. So listen to the audio and watch the slides together.

(9) Another POCUS HPVG case… Critical…or not?, March 1, 2019, by Dr. Phillipe Rola of Thinking Critical Care.

(10) The Andromeda-SHOCK trial with Korbin Haycock and the Nuclear Bomb Approach to Sepsis, Feb. 20, 2019, by Dr. Phillipe Rola of Thinking Critical Care.

(11) The Andromeda-SHOCK study. A physiological breakdown with Rory Spiegel (@EMnerd), Feb. 19, 2019, The Andromeda-SHOCK study. A physiological breakdown with Rory Spiegel (@EMnerd).

(*) Is POCUS the new PAC??? A Chat with Jon-Emile Kenny (@heart_lung), Feb 12, 2019,

(12) #POCUS IVC Pitfall Twitter Poll & Discussion, Dec. 27, 2018 by Dr. Philipe Rola of Thinking Critical Care.

(13) A Tale Of Salt And Water Congestion (Part 1), Dec 6, 2018 by Dr. Philipe Rola of Thinking Critical Care.

Dr. Rola references the following articles in the post above:

(A) Portal vein pulsatility ratio and heart failure [PubMed Abstract]. J Clin Ultrasound. 1998 Jan;26(1):27-31.

(B) Alterations in Portal Vein Flow and Intrarenal Venous Flow Are Associated With Acute Kidney Injury After Cardiac Surgery: A Prospective Observational Cohort Study [PubMed Abstract] [Full Text HTML] [Full Text PDF]. J Am Heart Assoc. 2018 Oct 2;7(19):e009961. doi: 10.1161/JAHA.118.009961.

(14) POCUS, Mythology and Hemodynamic Awesomeness with Jon and Korbin!, Nov. 11, 2018 by Dr. Philipe Rola of Thinking Critical Care.

(15) The First Steps Towards Physiological Resuscitation: A Team Effort , Nov 23, 2018

(16) Is POCUS the new PAC??? A Chat with Jon-Emile Kenny (@heart_lung), Feb. 12, 2019 by Dr. Philipe Rola of Thinking Critical Care.

The above link is to two excellent podcasts.

(17) Pulmonary Hypertension: Emergency Management, Primary Care Diagnosis, And Echocardiographic Evaluation
Posted on May 5, 2019 by Tom Wade MD

(18) Pulmonary Hypertension Infographic From The Curbsiders With Additional Resources
Posted on February 19, 2019 by Tom Wade MD

(19) “Pulmonary Hypertension: Diagnosis and Treatment” – Excerpts From American Family Physician 2016
Posted on July 29, 2018 by Tom Wade MD

(20) Emergency Recognition And Management Of Pulmonary Hypertension And RV Failure – Help From Drs. Wilcox and Weingart (EMCrit 181)
Posted on July 25, 2018 by Tom Wade MD

(21) Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Echo Res Pract. 2018 Sep; 5(3): G11–G24.


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