Especially in recent years, the use of point-of-care ultrasound by non-radiologist clinicians has become widespread. Point-of-care ultrasound provides rapid responses to the problems of critically ill patients at the bedside. This technique has many important advantages, including being non-invasive, cheap, repeatable, painless, and radiation-free. Numerous studies have revealed the most important clinical benefits of point-of-care ultrasound use by pediatric intensive care providers. The inferior vena cava is a vessel that is highly sensitive to fluid changes. The inferior vena cava diameter can be measured by a point-of-care ultrasound, and represents a critical parameter in assessing the patient's fluid status. The inferior vena cava collapsibility index (in spontaneously breathing patients) and the inferior vena cava distensibility index (in mechanically ventilated patients) are calculated by determined formulas by using maximum and minimum diameters of the inferior vena cava. The indices are important guides for pediatric intensive care providers for managing their patients' fluid treatment. Although some authors claim it is not a reliable method, the technique is coming to fore in intensive care units day by day, and has an increasing trend among pediatric intensive care specialists. Here, we aim to give detailed information on the ultrasonographic inferior vena cava diameter measurement methods, and calculations of the inferior vena cava collapsibility index and inferior vena cava distensibility index, and emphasize the importance of a noninvasive, bedside, and objective method of detecting the volume status of critically ill patients for pediatric intensive care specialists according to the published literature.

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Ultrasonographic inferior vena cava collapsibility and distensibility indices for detecting the volume status of critically ill pediatric patients

Central venous pressure, global end-diastolic index, and the inferior vena cava collapsibility/distensibility indices to estimate intravascular volume status in critically ill children: A pilot study.

ULTRASONOGRAPHY is a modern diagnostic tool both in intensive care and emergency medicine. Small, portable and simple ultrasound devices have been introduced due to technological advances. The image quality, size, and weight of portable ultrasound devices are improving. Prehospital point-of-care ultrasonog- raphy may have an impact on the decision making in prioritizing initial treatment. First aid at the scene of the accident and transporting the patient to the hospital is a key element, which in the case of appropriate diagnostics allows you to fight life-threatening injuries. The intention of using ultrasound protocols is to shorten and simplify the ultrasound examination allowing to eliminate or find complications of an injury as soon as possible. The protocols used include elements of ultrasonography and echocardiography of the lung tissue, abdominal cavity, pelvis, large vessels or the eyeball. The intention of the authors of the article was to present to the reader the basic ultrasound protocols applicable to patients in emergency situations.

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Application of interventional ultrasound in emergency medicine conditions

Fluid management is challenging in malaria patients given the risks associated with intravascular fluid depletion and iatrogenic fluid overload leading to pulmonary oedema. Given the limitations of the physical examination in guiding fluid therapy, we evaluated point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) and lungs as a novel tool to assess volume status and detect early oedema in malaria patients. To assess the correlation between IVC and lung ultrasound (LUS) indices and clinical signs of hypovolaemia and pulmonary oedema, respectively, concurrent clinical and sonographic examinations were performed in an observational study of 48 malaria patients and 62 healthy participants across age groups in Gabon. IVC collapsibility index (CI) ≥ 50% on enrolment reflecting intravascular fluid depletion was associated with an increased number of clinical signs of hypovolaemia in severe and uncomplicated malaria. With exception of dry mucous membranes, IVC-CI correlated with most clinical signs of hypovolaemia, most notably sunken eyes (r = 0.35, p = 0.0001) and prolonged capillary refill (r = 0.35, p = 0.001). IVC-to-aorta ratio ≤ 0.8 was not associated with any clinical signs of hypovolaemia on enrolment. Among malaria patients, a B-pattern on enrolment reflecting interstitial fluid was associated with dyspnoea (p = 0.0003), crepitations and SpO2 ≤ 94% (both p < 0.0001), but not tachypnoea (p = 0.069). Severe malaria patients had increased IVC-CI (p < 0.0001) and more B-patterns (p = 0.004) on enrolment relative to uncomplicated malaria and controls. In malaria patients, POCUS of the IVC and lungs may improve the assessment of volume status and detect early oedema, which could help to manage fluids in these patients.

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Point-of-care ultrasound to assess volume status and pulmonary oedema in malaria patients

Recently, the use of point-of-care ultrasonography (POCUS) by pediatricians especially in emergency and intensive care departments has become increasingly popular Critical care echocardiography (CCE) quickly and accurately identifies cardiac function, allowing intensivists to manage critically ill pediatric patients by manipulating vasoactive-inotrope-fluid treatment based on the echocardiographic results Training courses for POCUS are increasingly available and more intensivists are learning how to use CCE In this review, we focus on the importance and utility of CCE in pediatric intensive units and how it assists in the management of hemodynamically unstable pediatric patients We highlight the common measurements carried out by intensive care specialists and emphasize the role of the CCE methods in PICUs

A trend skill that makes pediatric intensivists stand out: Critical care echocardiography.

To find a correlation between inferior vena cava (IVC) diameters, IVC compressibility index (CI) and central venous pressure (CVP). Prospective observational study was done at pediatric intensive care unit (PICU) of Kalawati Saran Children’s Hospital (KSCH). Fifty children aged 5-18 y, presenting with shock were enrolled for the study. IVC diameters, CI and relevant clinical data were noted at enrollment, 30 min, 1 h, 6 h, and 12 h. Central line was placed at the time of admission. Of 50 children enrolled, 28 were boys, with a mean age of 11 y. More than 80% of cases were diagnosed as septic shock. Mean maximum and minimum IVC diameter of 8.3 ± 2 mm and 3.7 ± 1.7 mm, respectively CI 58.2 ± 7% and CVP of 5.4 ± 1.5 cm of H2O was observed at admission. CVP and IVC diameters showed a serial improvement with treatment; CI showed a serial decrease with treatment. Heart rate (HR) and systolic blood pressure (SBP) also showed a serial improvement at 12 h (p < 0.05). CVP showed a positive correlation with IVC diameter (r +0.312; p < 0.05), and a negative correlation with CI (r −0.343; p < 0.05). Effective fluid resuscitation improves IVC diameters with a decrease in CI. IVC diameter has a positive correlation to CVP and CI has a negative correlation to CVP.

The Correlation Between Inferior Vena Cava Diameter Measured by Ultrasonography and Central Venous Pressure.

To report a case of central retinal vein occlusion (CRVO) seven days following the first dose of ChAdOx1 nCoV-19 vaccine and propose a hypothesis for the possible underlying pathogenesis.A 31-year-old male presented with CRVO with cystoid macular edema, one week after receiving his first ChAdOx1 nCoV-19 vaccine dose. Apart from mild hyperhomocysteinemia, no major thrombophilic or systemic risk factors were found. Anti-platelet factor 4 antibodies, specific for vaccine-induced immune thrombotic thrombocytopenia, were also negative. However, he tested strongly positive (> 250 U/mL) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) IgG spike antibodies, 2 weeks post the first dose - suggestive of a prior subclinical infection.COVID-19 is known to be associated with an altered host one-carbon metabolism resulting in hyperhomocysteinemia. We hypothesize that a prior subclinical infection with COVID-19, the first hit, may have led to hyperhomocysteinemia in our patient and vaccination must have been the second hit that triggered the thrombotic event. Further studies, including correlation of thrombotic complications with IgG antibody titres post-vaccination, are essential in order to better understand the pathogenesis of such events. 

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Hans Vaish

Papers

The Correlation Between Inferior Vena Cava Diameter Measured by Ultrasonography and Central Venous Pressure.

Central retinal vein occlusion post ChAdOx1 nCoV-19 vaccination – can it be explained by the two-hit hypothesis?