A Non-invasive Method for Assessment of Intravascular Fluid Status: Inferior Vena Cava Diameters and Collapsibility Index.
TL;DR: There is a strong correlation between CVP and IVC diameters and the collapsibility index and this is a new formula for evaluating CVP, based on statistical analyses.
Abstract: OBJECTIVE To evaluate the correlation between central venous pressure (CVP) and inferior vena cava (IVC) diameters measured by ultrasonography (Ultrasound) in critically ill patients. METHODS Intubated critically ill patients were enrolled. The CVP values were measured using a U-tube manometer and were compared to the IVC diameters and collapsibility index, which were measured by bedside Ultrasound. Patients younger than 18 years old, who were not intubated, who had an abdominal pressure greater than 12 mmHg, and/or who were admitted for trauma were excluded from the study. RESULTS Eighty three patients with a mean age of 73.6±11.2 years were enrolled. The most common diagnosis was sepsis (21 patients, 25.30%). IVC inspiration measurements were statistically significantly correlated with CVP measurements (p0.05, r: 0.1). IVC collapsibility measurements showed a negative correlation with CVP measurements (p<0.01, r: 0.68). CONCLUSIONS There is a strong correlation between CVP and IVC diameters and the collapsibility index. This is a new formula for evaluating CVP, based on our statistical analyses.
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TL;DR: Ultrasound in combination with passive leg raise is a non-invasive, cost- and time-effective modality that can be employed to assess volume status and response to fluid resuscitation.
Abstract: Background Volume resuscitation has only been demonstrated to be effective in approximately fifty percent of patients. The remaining patients do not respond to volume resuscitation and may even develop adverse outcomes (such as acute pulmonary edema necessitating endotracheal intubation). We believe that point-of-care ultrasound is an excellent modality by which to adequately predict which patients may benefit from volume resuscitation. Data resources We performed a search using PubMed, Scopus, and MEDLINE. The following search terms were used: fluid responsiveness, ultrasound, non-invasive, hemodynamic, fluid challenge, and passive leg raise. Preference was given to clinical trials and review articles that were most relevant to the topic of assessing a patient's cardiovascular ability to respond to intravenous fluid administration using ultrasound. Results Point-of-care ultrasound can be easily employed to measure the diameter and collapsibility of various large vessels including the inferior vena cava, common carotid artery, subclavian vein, internal jugular vein, and femoral vein. Such parameters are closely related to dynamic measures of fluid responsiveness and can be used by providers to help guide fluid resuscitation in critically ill patients. Conclusion Ultrasound in combination with passive leg raise is a non-invasive, cost- and time-effective modality that can be employed to assess volume status and response to fluid resuscitation. Traditionally sonographic studies have focused on the evaluation of large veins such as the inferior vena cava, and internal jugular vein. A number of recently published studies also demonstrate the usefulness of evaluating large arteries to predict volume status.
27 citations
TL;DR: It is possible to reliably measure the caudal vena cava collapsibility index sonographically in healthy foals, and the CVC‐CI may prove useful in assessing the intravascular volume status in hypovolemic foals.
Abstract: Background
Intravascular volume assessment in foals is challenging. In humans, intravascular volume status is estimated by the caudal vena cava (CVC) collapsibility index (CVC-CI) defined as (CVC diameter at maximum expiration [CVCmax] – CVC diameter at minimal inspiration [CVCmin])/CVCmax × 100%.
Hypothesis/Objectives
To determine whether the CVC could be sonographically measured in healthy foals, determine differences in CVCmax and CVCmin, and calculate inter- and intrarater variability between 2 examiners. We hypothesized that the CVC could be measured sonographically at the subxiphoid view and that there would be a difference between CVCmax and CVCmin values.
Animals
Sixty privately owned foals <1-month-old.
Methods
Prospective study. A longitudinal subxiphoid sonographic window in standing foals was used. The CVCmax and CVCmin were analyzed by a linear mixed effect model. Inter-rater agreement and intrarater variability were expressed by Bland-Altman and intraclass correlation coefficients, respectively.
Results
Measurements were attained from 58 of 60 foals with mean age of 15 ± 7.9 days and mean weight of 75.7 ± 17.7 kg. The CVCmax was significantly different from CVCmin (D = 0.515, SE = 0.031, P < 0.001). Inter-rater agreement of the CVC-CI differed by an average of −0.9% (95% limits of agreement, −12.5 to +10.7%). Intrarater variability of CVCmax was 0.540 and 0.545, of CVCmin was 0.550 and 0.594, and of CVC-CI was 0.894 and 0.853 for observers 1 and 2, respectively.
Conclusions and Clinical Importance
These results indicate it is possible to reliably measure the CVC sonographically in healthy foals, and the CVC-CI may prove useful in assessing the intravascular volume status in hypovolemic foals.
10 citations
Cites background from "A Non-invasive Method for Assessmen..."
...The American Society of Echocardiography and the European Association of Cardiovascular Imaging recommends that CVC diameter and CVC-CI be used together to determine right atrial (RA) pressure.(13,16) Studies investigating the CVC and the CVC-CI in equine neonates are lacking....
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TL;DR: It is concluded that IVCCI is not a predictor of PSH in pregnant women undergoing elective cesarean section and inferior vena cava collapsibility index (IVCCI) will be able to identify hypovolemic parturients.
Abstract: Background: Postspinal anesthesia hypotension (PSH) in pregnant women is common and may lead to poor maternal and fetal outcome. Fluid loading in pregnant women before spinal anesthesia to prevent hypotension is of limited ability. We hypothesized that those women who are hypovolemic before spinal anesthesia may be at risk of PSH and inferior vena cava collapsibility index (IVCCI) will be able to identify hypovolemic parturients. Methods: In this prospective observational study, n = 45 women undergoing elective lower segment cesarean section with singleton pregnancy were recruited and IVCCI in left lateral tilt (with wedge) and supine position (without wedge) were noted by M-mode ultrasound (USG) before spinal anesthesia. After spinal anesthesia, changes in blood pressure were noted till 15 min after spinal anesthesia. Results: USG measurements were obtained in 40 patients and 23 of 40 patients (57.5%) had at least one episode of hypotension. Area under the ROC curve of IVCCI with wedge to predict PSH was 0.46 (95% CI 0.27, 0.64) and best cut-of value was 25.64 with a sensitivity and specificity of 60.9% and 35.5%, respectively. Area under the ROC curve of IVCCI without wedge to predict PSH was 0.38 (95% CI 0.19, 0.56) and best cut-of value was 20.4 with a sensitivity and specificity of 69.6% and 23.5%, respectively. Conclusion: We conclude that IVCCI is not a predictor of PSH in pregnant women undergoing elective cesarean section.
7 citations
TL;DR: In this article , the authors evaluated the effectiveness of the Inferior Vena Cava Collapsibility Index (IVCCI) for predicting intraoperative hypotension in elective surgical procedures.
4 citations
TL;DR: IVCCI and IJVCI are efficacious and reliable tools in predicting PSAH in pregnant ladies undergoing cesarean section, with a slight superiority for IVCCI regarding specificity and accuracy.
Abstract: Background Post spinal anesthesia hypotension (PSAH) is frequently encountered in anesthetic practice, especially during cesarean section. Ultrasound is a safe and easy technique for hemodynamic monitoring. Objectives This study was conducted to assess the efficacy of pre-operative inferior vena cava collapsibility index (IVCCI) and internal jugular vein collapsibility index (IJVCI) in predicting PSAH. Methods This cross-sectional blinded study included 55 pregnant females prepared for elective cesarean section. They were divided into two groups based on the incidence of PSAH: (1) cases with PSAH (26 cases); and (2) cases without PSAH (29 cases). All the cases underwent ultrasound-guided measurement of IVCCI and IJVCI. The efficacy of these parameters was assessed in predicting PSAH. Results Cases in both groups expressed non-significant differences regarding demographic data. However, IVCCI had mean values of 38.27 and 23.97%, while IJVCCI had mean values of 46.50 and 33.41%, respectively, in cases with and without PSAH. For IVCCI, using a cut-off point of 33% had sensitivity and specificity (84.6 and 93.1%, respectively) for predicting PSAH, with a diagnostic accuracy of 89.1%. IJVCI had sensitivity and specificity of 84.6 and 82.8%, respectively, for predicting the same complication using a cut-off value of 38.5%. Conclusion IVCCI and IJVCI are efficacious and reliable tools in predicting PSAH in pregnant ladies undergoing cesarean section, with a slight superiority for IVCCI regarding specificity and accuracy.
2 citations
References
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TL;DR: RHC was associated with increased mortality and increased utilization of resources, and these findings justify reconsideration of a randomized controlled trial of RHC and may guide patient selection for such a study.
Abstract: Objective To examine the association between the use of right heart catheterization (RHC) during the first 24 hours of care in the intensive care unit (ICU) and subsequent survival, length of stay, intensity of care, and cost of care. Design Prospective cohort study. Setting Five US teaching hospitals between 1989 and 1994. Subjects A total of 5735 critically ill adult patients receiving care in an ICU for 1 of 9 prespecified disease categories. Main outcome measures Survival time, cost of care, intensity of care, and length of stay in the ICU and hospital, determined from the clinical record and from the National Death Index. A propensity score for RHC was constructed using multivariable logistic regression. Case-matching and multivariable regression modeling techniques were used to estimate the association of RHC with specific outcomes after adjusting for treatment selection using the propensity score. Sensitivity analysis was used to estimate the potential effect of an unidentified or missing covariate on the results. Results By case-matching analysis, patients with RHC had an increased 30-day mortality (odds ratio, 1.24; 95% confidence interval, 1.03-1.49). The mean cost (25th, 50th, 75th percentiles) per hospital stay was $49 300 ($17 000, $30 500, $56 600) with RHC and $35 700 ($11 300, $20 600, $39 200) without RHC. Mean length of stay in the ICU was 14.8 (5, 9, 17) days with RHC and 13.0 (4, 7, 14) days without RHC. These findings were all confirmed by multivariable modeling techniques. Subgroup analysis did not reveal any patient group or site for which RHC was associated with improved outcomes. Patients with higher baseline probability of surviving 2 months had the highest relative risk of death following RHC. Sensitivity analysis suggested that a missing covariate would have to increase the risk of death 6-fold and the risk of RHC 6-fold for a true beneficial effect of RHC to be misrepresented as harmful. Conclusion In this observational study of critically ill patients, after adjustment for treatment selection bias, RHC was associated with increased mortality and increased utilization of resources. The cause of this apparent lack of benefit is unclear. The results of this analysis should be confirmed in other observational studies. These findings justify reconsideration of a randomized controlled trial of RHC and may guide patient selection for such a study.
1,385 citations
Foothills Medical Centre1, University of Calgary2, Ghent University Hospital3, McMaster University4, Fremantle Hospital5, Tulane University6, Uppsala University7, University of Helsinki8, Loma Linda University9, University College Hospital10, Orlando Regional Medical Center11, VCU Medical Center12, University of Tartu13, University of Western Australia14, University of Notre Dame15, John Hunter Hospital16, Liverpool Hospital17, Albert Einstein Medical Center18, University of Utah19, Universidad Anáhuac México Norte20
TL;DR: The overall quality of evidence available to guide development of RECOMMENDATIONS was generally low and Appropriately designed intervention trials are urgently needed for patients with IAH and ACS.
Abstract: Purpose
To update the World Society of the Abdominal Compartment Syndrome (WSACS) consensus definitions and management statements relating to intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS).
1,100 citations
Journal Article•
873 citations
TL;DR: Analysis of ΔDIVC is a simple and non-invasive method to detect fluid responsiveness in mechanically ventilated patients with septic shock and identified responders with positive and negative predictive values of 93% and 92%, respectively.
Abstract: To investigate whether the respiratory variation in inferior vena cava diameter (ΔDIVC) could be related to fluid responsiveness in mechanically ventilated patients. Prospective clinical study. Medical ICU of a non-university hospital. Mechanically ventilated patients with septic shock (n=39). Volume loading with 8 mL/kg of 6% hydroxyethylstarch over 20 min. Cardiac output and ΔDIVC were assessed by echography before and immediately after the standardized volume load. Volume loading induced an increase in cardiac output from 5.7±2.0 to 6.4±1.9 L/min (P<0.001) and a decrease in ΔDIVC from 13.8±13.6 vs 5.2±5.8% (P<0.001). Sixteen patients responded to volume loading by an increase in cardiac output ≥15% (responders). Before volume loading, the ΔDIVC was greater in responders than in non-responders (25±15 vs 6±4%, P<0.001), closely correlated with the increase in cardiac output (r=0.82, P<0.001), and a 12% ΔDIVC cut-off value allowed identification of responders with positive and negative predictive values of 93% and 92%, respectively. Analysis of ΔDIVC is a simple and non-invasive method to detect fluid responsiveness in mechanically ventilated patients with septic shock.
762 citations
TL;DR: Despite the widespread use of this procedure and its attendant costs, there is no evidence that it benefits patients, and its use has not been shown to decrease patient morbidity or mortality.
Abstract: Pulmonary artery (PA) catheterization is performed daily in hospitals around the world. The hemodynamic data derived from PA catheterization are used to determine, monitor, and modify therapy in critically ill and/or hemodynamically unstable patients, including those with acute myocardial infarction (MI), congestive heart failure (CHF), and multiorgan failure, and they are frequently used to monitor patients with heart disease who undergo cardiac or noncardiac surgery. More than 1 million PA catheters are sold in the United States each year, and the annual costs associated with the use of PA catheters exceed $2 billion a year. Despite the widespread use of this procedure and its attendant costs, there is no evidence that it benefits patients. Its use has not been shown to decrease patient morbidity or mortality. To the contrary, there is evidence that it may increase morbidity and mortality. How Did We Get Here? Pulmonary artery catheterization was first performed
388 citations