Fluid resuscitation is a central and early component of septic shock management. However, observational studies across multiple critical care populations have demonstrated that patients with greater cumulative fluid balance experience increased rates of organ dysfunction, prolonged mechanical ventilation, and increased mortality.1 These findings may be a result of venous congestion, which has been associated with acute kidney injury (AKI) and worse clinical outcomes.2 The challenge lies in determining when to begin the deresuscitation phase, where fluid is deliberately removed after initial resuscitation. Bedside ultrasound is increasingly emerging as a useful tool to guide this decision through direct assessment of systemic congestion.3
Several related concepts are helpful to clarify. Fluid overload is a state of abnormal expansion of the intravascular compartment.4 Fluid responsiveness refers to the ability of a patient to increase stroke volume and cardiac output (typically by > 10%) in response to a fluid bolus, indicating that they are on the ascending portion of the Frank-Starling curve.3 Venous congestion refers to elevated central venous pressure transmitted to end organs, causing organ dysfunction through increased back pressure and organ edema.5
The ROSE model outlines four phases of fluid therapy during critical illness: resuscitation, optimization, stabilization, and evacuation. The evacuation phase represents the period when excess fluid is actively removed once hemodynamic stability has been achieved.1,6 Traditional markers used to guide fluid removal such as cumulative fluid balance, body weight changes, and physical exam provide only indirect information regarding the physiologic consequences of fluid accumulation. Bedside ultrasound offers an important advantage by allowing the physiologic effects of fluid accumulation to be visualized directly and repeatedly during the ICU stay.7–9
Lung ultrasound is one of the most widely adopted ultrasound applications in critical care and provides a rapid method to assess pulmonary congestion. The presence of B-lines indicates interstitial fluid within the lung and correlates well with pulmonary edema with a sensitivity of 88% to 94% and a pooled specificity of 87% to 92% across multiple meta-analyses.8,10–12 Lung ultrasound can also be used dynamically to monitor pulmonary congestion during fluid management. Serial lung ultrasound examinations may help assess response to active fluid removal as pulmonary edema resolves.13
Ultrasound assessment of systemic venous congestion has also grown in popularity.14–15 The venous excess ultrasound score (VExUS) integrates inferior vena cava (IVC) measurements with Doppler assessments of the hepatic, portal, and intrarenal veins to estimate the severity of venous congestion.14 Initial literature from the cardiac surgery population demonstrated that severe venous congestion identified by VExUS was associated with the development of AKI.16 Subsequent prospective ICU studies and systematic reviews suggest that VExUS may identify clinically relevant venous congestion in critically ill patients, especially in relation to renal injury risk. It is important to note that randomized trials demonstrating improved outcomes with VExUS-guided management in the ICU population are still lacking.7,13 The Andromeda-VEXUS study is underway. This is an international, multicenter, prospective, observational study evaluating the association between venous congestion and the provision of renal replacement therapy or death within 28 days in patients with septic shock.17
Recent studies have also evaluated ultrasound jugular venous point (uJVP) assessment as a noninvasive estimate of right atrial pressure (RAP). In this technique the patient is positioned semi-upright (30 to 45 degrees), and a linear probe is advanced cranially along the internal jugular vein until the point where the vessel collapses during respiration. The vertical height of this collapse point relative to the sternal angle is measured, and 5 cm is added to estimate jugular venous pressure and correlated with invasively measured right atrial pressure.
In prospective validation against hemodynamic measurements in heart failure patients, uJVP had an area under the curve of 0.84 for predicting elevated RAP (> 10 mmHg) and was 94% specific for patients in the upright position.18 Although it has not been specifically studied in ICU populations to guide deresuscitation, uJVP may be a promising adjunct for estimating central venous pressure and supporting bedside assessment of venous congestion.
A recent systematic review of deresuscitation strategies in septic shock found no clear mortality benefit in randomized trials. However, several trials did not achieve substantial differences in fluid balance between intervention and control groups, which may have limited the ability to detect meaningful effects. In contrast, the larger body of observational studies in this review and meta-analysis suggested potential advantages.19 These studies reported associations between deresuscitation and improved cumulative fluid balance, reduced duration of mechanical ventilation, and shorter ICU length of stay.19 Reduction of systemic venous congestion may improve organ perfusion, particularly in the kidneys, where venous congestion has been associated with AKI.16,20
CONFIDENCE, an ongoing study evaluating the effect of lung ultrasound-guided fluid deresuscitation on duration of ventilated patients in the ICU, is a multicenter randomized controlled trial evaluating critically ill adult patients who require invasive mechanical ventilation. The patients are randomized to a daily lung ultrasound-guided deresuscitation group or a usual care group. The primary outcome is ventilator-free days at day 28.21
The role of ultrasound-guided deresuscitation strategies remains an area of ongoing investigation and further research is needed to demonstrate whether these strategies can improve patient outcomes. Bedside ultrasound allows for direct assessment of physiologic responses to fluid management in real time. As evidence continues to develop, integrating lung ultrasound, venous Doppler assessment, cardiac ultrasound, and uJVP may allow clinicians to more accurately identify when patients may benefit from more aggressive fluid removal.
References
1. Malbrain MLNG, Martin G, Ostermann M. Everything you need to know about deresuscitation. Intensive Care Med. 2022;48(12):1781-1786. doi:10.1007/s00134-022-06761-7
2. Wang N, Jiang L, Zhu B, Wen Y, Xi XM, Beijing Acute Kidney Injury Trial (BAKIT) Workgroup. Fluid balance and mortality in critically ill patients with acute kidney injury: a multicenter prospective epidemiological study. Crit Care. 2015;19:371. doi:10.1186/s13054-015-1085-4
3. Zampieri FG, Bagshaw SM, Semler MW. Fluid therapy for critically ill adults with sepsis: a review. JAMA. 2023;329(22):1967. doi:10.1001/jama.2023.7560
4. Drum B, La Course B, Kelly M, et al. Does this patient have volume overload? The rational clinical examination. JAMA. 2026;335(13):1159-1168. doi:10.1001/jama.2026.0446
5. Husain-Syed F, McCullough PA, Birk HW, et al. Cardio-pulmonary-renal interactions. JACC. 2015;65(22):2433-2448. doi:10.1016/j.jacc.2015.04.024
6. Hoste EA, Maitland K, Brudney CS, et al. Four phases of intravenous fluid therapy: a conceptual model. Br J Anaesth. 2014;113(5):740-47. doi:10.1093/bja/aeu300
7. Cordemans C, De Laet I, Van Regenmortel N, et al. Fluid management in critically ill patients: the role of extravascular lung water, abdominal hypertension, capillary leak, and fluid balance. Ann Intensive Care. 2012;2(suppl 1):S1. doi:10.1186/2110-5820-2-S1-S1
8. Liu RB, Donroe JH, McNamara RL, Forman HP, Moore CL. The practice and implications of finding fluid during point-of-care ultrasonography: a review. JAMA Intern Med. 2017;177(12):1818-1825. doi:10.1001/jamainternmed.2017.5048
9. Rice JA, Brewer J, Speaks T, Choi C, Lahsaei P, Romito BT. The POCUS consult: how point of care ultrasound helps guide medical decision making. Int J Gen Med. 2021;14:9789-9806. doi:10.2147/IJGM.S339476
10. Dong LJ, Li J, Liu W, et al. Diagnostic efficacy of lung ultrasound in cardiogenic pulmonary edema: a systematic review and meta-analysis. Eur Rev Med Pharmacol Sci. 2023;27(15):6947-955. doi:10.26355/eurrev_202308_33267
11. Gartlehner G, Wagner G, Affengruber L, et al. Point-of-care ultrasonography in patients with acute dyspnea: an evidence report for a clinical practice guideline by the American College of Physicians. Ann Intern Med. 2021;174(7):967-976. doi:10.7326/M20-5504
12. Wang Y, Shen Z, Lu X, Zhen Y, Li H. Sensitivity and specificity of ultrasound for the diagnosis of acute pulmonary edema: a systematic review and meta-analysis. Med Ultrason. 2018;1(1):32-36. doi:10.11152/mu-1223
13. da Hora Passos R, Andari LVDWBU, de Almeida Lopes M, Galindo VB, Flato UAP, Narciso RC, et al. The role of thoracic ultrasound in fluid management in critical care: a narrative review. J Thorac Dis. 2026 Jan 31;18(1):40. doi:10.21037/jtd-2025-1103
14. 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. doi:10.1186/s13089-020-00163-w
15. Rola P, Miralles-Aguiar F, Argaiz E, et al. Clinical applications of the venous excess ultrasound (VExUS) score: conceptual review and case series. Ultrasound J. 2021;13(1):32. doi:10.1186/s13089-021-00232-8
16. Beaubien-Souligny W, Benkreira A, Robillard P, et al. Alterations in portal vein flow and intrarenal venous flow are associated with acute kidney injury after cardiac surgery: a prospective observational cohort study. J Am Heart Assoc. 2018;7(19):e009961. doi:10.1161/JAHA.118.009961
17. Prager R, Argaiz E, Pratte M, et al. Doppler identified venous congestion in septic shock: protocol for an international, multi-centre prospective cohort study (Andromeda-VEXUS). BMJ Open. 2023;13(7):e074843. doi:10.1136/bmjopen-2023-074843
18. Wang L, Harrison J, Dranow E, Aliyev N, Khor L. Accuracy of ultrasound jugular venous pressure height in predicting central venous congestion. Ann Intern Med. 2022;175(3):344–351. doi:10.7326/M21-2781
19. Messmer AS, Dill T, Müller M, Pfortmueller CA. Active fluid de-resuscitation in critically ill patients with septic shock: A systematic review and meta-analysis. Eur J Intern Med. 2023;109:89-96. doi:10.1016/j.ejim.2023.01.009
20. Melo RH, Gioli-Pereira L, Melo E, Rola P. Venous excess ultrasound score association with acute kidney injury in critically ill patients: a systematic review and meta-analysis of observational studies. Ultrasound J. 2025;17(1):16. doi:10.1186/s13089-025-00413-9
21. Blok SG, Mousa A, Brouwer MG, et al. Effect of lung ultrasound-guided fluid deresuscitation on duration of ventilation in intensive care unit patients (CONFIDENCE): protocol for a multicentre randomised controlled trial. Trials. 2023;24(1):226. doi:10.1186/s13063-023-07171-w
