Core IM | Internal Medicine Podcast #193 Venous Congestion & VEXUS Interview with Dr. Ross Prager
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Nov 19, 2025 Dr. Ross Pacher, an intensivist and researcher, dives into the nuanced world of venous congestion and its critical implications. He clarifies the distinction between venous congestion and volume overload, revealing how venous Doppler assessments can illuminate issues like AKI and delirium. Pacher shares practical insights on using the VEXUS score while outlining common pitfalls and the importance of measuring ultrasound markers in acute care. He discusses optimal fluid management strategies and highlights when to reassess congestion during treatment.
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Venous Congestion Versus Volume Overload
- Venous congestion is retrograde flow from the right atrium into end organs and differs from volume overload.
- Patients can have severe congestion without overt peripheral edema, so assess organ-level effects not just visible fluid.
Flow Over Pressure For Organ Injury
- Elevated central venous pressure correlates with harm but poorly predicts individual outcomes because organ pressures and flow matter more.
- Retrograde venous flow (congestion) likely drives organ dysfunction more than static pressure alone.
Delirium Linked To Venous Congestion
- Dr. Pacher's group found venous congestion links to cerebral desaturations and worse delirium after cardiac surgery.
- He suggests some unexplained ICU delirium might improve with targeted diuresis addressing congestion.