Q&A

Q: How does VEXUS differ from current fluid management strategies?

A: Unlike physical exam or radiographic signs that detect fluid overload late, VEXUS uses Doppler ultrasound of hepatic, portal, and intra-renal veins to identify venous congestion earlier, guiding when to restrict fluids or initiate de-resuscitation.

Q: When is the patient included?

A: The patient should be included within 16 hours of ICU admission with a diagnosis of septic shock.

Q: When should the VEXUS and POCUS scan be done?

A: The POCUS team should scan the patient within 6 hours of inclusion and daily for 3 days. Fluid management is tailored based on congestion severity:.

Q: Till when the VESPER protocol is applied?

A: The protocol is conducted for a total of 3 days.

Q: How will the treating team know the congestion level and what management to follow for each enrolled patient?

A: The research team will review the VEXUS and POCUS scans, then place a bedside sign at the patient’s head side of the bed showing the patient’s congestion level (no, mild, or severe congestion). They will also enter a standardized “order set” in PowerChart, which outlines the fluid, medication, and some communication orders.

Q: What happens with the control arm?

A: They receive the usual septic shock care (per Surviving Sepsis Campaign), but VEXUS is not performed among those patients during the first 3 days. However, POCUS for heart/lung may be used as clinically indicated.

Q: Which fluid balance should be followed in VEXUS group with sever congestion?

A: The balance is checked every 6 hours and is calculated manually by clicking on the hourly “lview / I&Q” charting and summate the net balance of each hour.

Q: What kind of fluid is not subjective to restricting their volume in VEXUS group with moderate\sever congestion?

A: Nutrition or blood products when clinically indicated should be administered as standard of care.

Q: When to hold the diuresis?

A: If patients develop adverse event like hypernatremia (Na > 155), alkalemia due to metabolic alkalosis (pH > 7.55), hypomagnesemia (Mg < 60), then we will withhold diuretic administration until biochemical derangements are corrected, then diuresis can be resumed again.

Q: What if a patient needs fluids despite congestion?

A: “Rescue fluid boluses” are permitted if the patient is fluid responsive and meets criteria such as severe or refractory hypotension, rising lactate, or prolonged capillary refill despite vasopressors. The treating physician always retains discretion.

Q: Why only 3 days of intervention?

A: Most septic shock patients develop fluid overload within 3–5 days, and RRT initiation or death peaks in this window.