Pediatric Venous Excess Ultrasound Score (P-VExUS): a novel approach to assess central venous pressure in the PICU

Accurate assessment of central venous pressure (CVP) in critically ill children is important for guiding fluid management but remains challenging, as invasive monitoring is not always feasible and noninvasive tools are limited. We aimed to develop and validate pediatric adaptations of the Venous Excess Ultrasound Score (P-VExUS) for bedside estimation of CVP in mechanically ventilated children. This prospective observational study was conducted in a tertiary-care PICU. Fifty-six mechanically ventilated children were included. Venous Doppler ultrasonography of the inferior vena cava, hepatic, portal, and intrarenal veins was performed at the bedside. Two P-VExUS models were evaluated: (1) a categorical grading system (0-III) and (2) a semiquantitative point-based score (0-7). Diagnostic performance was assessed for predefined, clinically relevant CVP thresholds reflecting low (< 7 mmHg) and elevated (> 12 mmHg) venous pressure states using receiver operating characteristic analysis. Both models were significantly associated with measured CVP. For predicting elevated CVP, model 1 showed an area under the receiver operating characteristic curve (AUROC) of 0.74 (95% CI 0.61-0.85), with 45% sensitivity and 98% specificity. Model 2 demonstrated superior accuracy (AUROC 0.94, 95% CI 0.84-0.98), with 82% sensitivity and 91% specificity (p < 0.001). For detecting low CVP, model 2 also outperformed model 1 (AUROC 0.80 vs. 0.69; p = 0.02). Intrarenal vein patterns had the highest discriminative ability (AUROC 0.92). CONCLUSION: Pediatric-specific P-VExUS models were feasible and accurate for estimating CVP in critically ill children. The point-based model showed superior diagnostic performance and may represent a promising noninvasive bedside tool for assessing venous congestion. WHAT IS KNOWN: • Elevated central venous pressure (CVP) is associated with adverse outcomes in critically ill children, including mortality and renal dysfunction. • Inferior vena cava-based ultrasound indices have limited accuracy for estimating CVP in mechanically ventilated children, while pediatric adaptations of the Venous Excess Ultrasound Score (VExUS) remain poorly defined. WHAT IS NEW: • This study proposes and evaluates two pediatric adaptations of VExUS, demonstrating superior diagnostic performance of a point-based model for identifying elevated (12 mmHg) and low (7 mmHg) CVP. • Intrarenal venous Doppler showed the highest individual discriminative performance, suggesting potential simplification of venous congestion assessment in critically ill children.