Journal Article•
Inferior vena cava diameter and collapsibility index: a practical non-invasive evaluation of intravascular fluid volume in critically-ill patients.
01 Mar 2013-Journal of the Medical Association of Thailand Chotmaihet thangphaet (J Med Assoc Thai)-Vol. 96, Iss: 3, pp 14
TL;DR: The authors conclude that the inferior vena cava diameter and collapsibility index (IVC-CI) can provide a useful guide for noninvasive intravascular volume status assessment of critically-ill patients.
Abstract: Background: Assessment of intravascular volume status is an essential parameter for the diagnosis and management of critically-ill patients. Generally, central venous pressure (CVP), which is an invasive measure, has been recommended for this purpose. Since CVP has been associated with many complications, inferior vena cava diameter and collapsibility index (IVC-CI) were used in the present study to evaluate the intravascular volume status of critically-ill patients at Rajavithi Hospital. Objective: To conduct a prospective, cross-sectional study to evaluate the IVC diameter as a guidance for estimating the volume status in critically-ill patients by bedside ultrasonography, focusing on correlations between CVP and IVC-CI and IVC diameter. Material and Method: Critically-ill patients who had been placed with a functioning central venous catheter were prospectively enrolled. Evaluation of intravascular volume status was performed by bedside ultrasonography to measure the IVC diameters (IVCD), both end-inspiratory (iIVCD) and end-expiratory (eIVCD). The IVC collapsibility indices (IVC-CI) were calculated by an equation and then were compared with the CVP values. Results: Of the 70 enrolled patients, with a mean age of 63.8 + 1.9 years, 64.3% were intubated. The most common indication of ICU admission was sepsis with hemodynamic instability (80.0%). The volume status of patients was stratified by their CVP levels as hypovolemic 15.7%, euvolemic 32.9% and hypervolemic 51.4% which correspond with the IVC-CI of 45.69 + 16.16%, 31.23 + 16.77%, and 17.82 + 12.36% respectively (p < 0.001). The highest significant correlation was found between the CVP and IVC-CI (r = -0.612, p < 0.001). In addition, there was a significant correlation between CVP and iIVCD (r = 0.535, p < 0.001); and between the CVP and mean IVCD (r = 0.397, p = 0.001). Conclusion: The present study supported the correlation between CVP and IVC-CI. The authors conclude that the IVC-CI can provide a useful guide for noninvasive intravascular volume status assessment of critically-ill patients. Keywords: Central venous pressure, Inferior vena cava diameter, Collapsibility index, Intravascular fluid volume, Ultrasonography
Citations
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TL;DR: There is a positive relationship of CVP with minimum and maximum IVC diameters but an inverse relationship with the IVC collapsibility index.
Abstract: OBJECTIVE The objective of our study is to assess the correlation between inferior vena cava (IVC) diameters, central venous pressure (CVP) and the IVC collapsibility index for estimating the volume status in critically ill patients. METHODS This cross-sectional study used the convenient sampling of 100 adult medical intensive care unit (ICU) patients for a period of three months. Patients ≥ 18 years of age with an intrathoracic central venous catheter terminating in the distal superior vena cava connected to the transducer to produce a CVP waveform were included in the study. A Mindray diagnostic ultrasound system model Z6 ultrasound machine (Mindray, NJ, USA) was used for all examinations. An Ultrasonic Transducer model 3C5P (Mindray, NJ, USA) for IVC imaging was utilized. A paired sampled t-test was used to compute the p-values. RESULTS A total of 32/100 (32%) females and 68/100 (68%) males were included in the study with a mean age of 50.4 ± 19.3 years. The mean central venous pressure maintained was 10.38 ± 4.14 cmH2O with an inferior vena cava collapsibility index of 30.68 ± 10.93. There was a statistically significant relation among the mean CVP pressure, the IVC collapsibility index, the mean maximum and minimum IVC between groups as determined by one-way analysis of variance (ANOVA) (p < 0.001). There was a strong negative correlation between CVP and IVC collapsibility index (%), which was statistically significant (r = -0.827, n = 100, p < 0.0005). A strong positive correlation between CVP and maximum IVC diameter (r = 0.371, n = 100, p < 0.0005) and minimum IVC diameter (r = 0.572, n = 100, p < 0.0005) was found. CONCLUSION There is a positive relationship of CVP with minimum and maximum IVC diameters but an inverse relationship with the IVC collapsibility index.
52 citations
TL;DR: This study represents a step forward in the area of intravascular volume estimation using IVC-CI, but the findings must be applied with caution owing to some methodologic limitations.
Abstract: BACKGROUNDIn search of a standardized noninvasive assessment of intravascular volume status, we prospectively compared the sonographic inferior vena cava collapsibility index (IVC-CI) and central venous pressures (CVPs). Our goals included the determination of CVP behavior across clinically relevant
50 citations
Cites background from "Inferior vena cava diameter and col..."
...It meets many of the desired criteria listed earlier, as it is relatively affordable and has been shown to be feasible to learn and perform in a short amount of time with minimal training, and increasing body of data suggests that it supplies clinically relevant and reliable information to the intensivist.(3,6) However, it also has technical (i....
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TL;DR: The measurements of minimum and maximum IVC diameters were moderately reliable by emergency residents and the interrater reliability of measurements in patients with profound and superficial located IVC is higher than that of measurementsin patients with moderate-depth locatedIVC.
Abstract: Objective Ultrasonography (US) has gained popularity in the emergency medicine to assess intravascular volume status in critically ill patients. However, there are a limited number of studies on the interrater reliability of US examination of the inferior vena cava (IVC) by emergency residents. Method One hundred eighty US examinations were performed on 90 emergency critical care unit patients by 6 emergency medicine residents. Minimum and maximum IVC diameters during normal passive inspiration were measured, and the IVC index was calculated. The interrater reliability of the measurable data was analyzed using intraclass correlation coefficients. Results The measurements of minimum and maximum IVC diameters were moderately reliable by emergency residents ( κ = 0.60 [95% confidence interval {CI}, 0.45-0.72] and κ = 0.56 [95% CI, 0.41-0.69], respectively). In the patients with moderate IVC depth (8.5-12.5 cm), the interrater reliabilities of sonographers were κ = 0.51 (95% CI, 0.30-0.67) for maximum diameter and κ = 0.43 (95% CI, 0.21-0.61) for minimum diameter. In patients with superficial (≤8.5 cm) and profound located (≥12.5 cm) IVC, the interrater reliabilities of sonographers for maximum and minimum diameters were κ = 0.69 (95% CI, 0.29-0.89) and κ = 0.75 (95% CI, 0.4-0.91), and κ = 0.58 (95% CI, 0.09-0.85) and κ = 0.76 (95% CI, 0.39-0.92), respectively. Conclusion The measurement of the IVC is moderately reliable by emergency residents. The interrater reliability of measurements in patients with profound and superficial located IVC is higher than that of measurements in patients with moderate-depth located IVC.
47 citations
Cites methods from "Inferior vena cava diameter and col..."
...Inferior vena cava (IVC) ultrasound is an effective method of assessing intravascular volume status [3–5]....
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TL;DR: JVP evaluation is the most sensitive physical examination technique in CVP assessments and the PVC techniques along with the newly described Anthem sign may be of value for the early learner who still has not mastered the art of JVP assessment and in obese patients in whom JVP Evaluation is problematic.
Abstract: Background
Noninvasive evaluation of central venous pressure (CVP) can be achieved by assessing the Jugular Venous Pressure (JVP), Peripheral Venous Collapse (PVC), and ultrasound visualization of the inferior vena cava. The relative accuracy of these techniques compared to one another and their application by trainees of varying experience remains uncertain. We compare the application and utility of the JVP, PVC, and handheld Mini Echo amongst trainees of varying experience including a medical student, internal medicine resident, and cardiology fellow. We also introduce and validate a new physical exam technique to assess central venous pressures, the Anthem sign.
33 citations
TL;DR: Respiratory movements have a major influence on IVC dynamics, and the increase in intracaval pressure during Valsalva results in a significant decrease in the IVC cross-sectional area.
Abstract: AIM: To study changes produced within the inferior vena cava (IVC) during respiratory movements and identify their possible clinical implications.
METHODS: This study included 100 patients (46 women; 54 men) over 18 years of age who required an abdominal computed tomography (CT) and central venous access. IVC cross-sectional areas were measured on CT scans at three levels, suprarenal (SR), juxtarenal (JR) and infrarenal (IR), during neutral breathing and again during the Valsalva maneuver. All patients were instructed on how to perform a correct Valsalva maneuver. In order to reduce the total radiation dose in our patients, low-dose CT protocols were used in all patients. The venous blood pressure (systolic, diastolic and mean) was invasively measured at the same three levels with neutral breathing and the Valsalva maneuver during venous port implantation. From CT scans, three-dimensional models of the IVC were constructed and a collapsibility index was calculated for each patient. These data were then correlated with venous pressures and cross-sectional areas.
RESULTS: The mean patient age was 51.64 ± 12.01 years. The areas of the ellipse in neutral breathing were 394.49 ± 85.83 (SR), 380.10 ± 74.55 (JR), and 342.72 ± 49.77 mm2 (IR), and 87.46 ± 18.35 (SR), 92.64 ± 15.36 (JR) and 70.05 ± 9.64 mm2 (IR) during the Valsalva (Ps < 0.001). There was a correlation between areas in neutral breathing and in the Valsalva maneuver (P < 0.05 in all areas). Large areas decreased more than smaller areas. The collapsibility indices were 0.49 ± 0.06 (SR), 0.50 ± 0.04 (JR) and 0.50 ± 0.04 (IR), with no significant differences in any region. Reconstructed three-dimensional models showed a flattening of the IVC during Valsalva, adopting an ellipsoid cross-sectional shape. The mean pressures with neutral breathing were 9.44 ± 1.78 (SR), 9.40 ± 1.44 (JR) and 8.84 ± 1.03 mmHg (IR), and 81.08 ± 21.82 (SR), 79.88 ± 19.01 (JR) and 74.04 ± 16.56 mmHg (IR) during Valsalva (Ps < 0.001). There was a negative correlation between cross-sectional caval area and venous blood pressure, but this was not statistically significant in any of the cases. There was a significant correlation between diastolic and mean pressures measured during neutral breathing and in Valsalva.
CONCLUSION: Respiratory movements have a major influence on IVC dynamics. The increase in intracaval pressure during Valsalva results in a significant decrease in the IVC cross-sectional area.
32 citations
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23,447 citations
TL;DR: A systematic review of the literature demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/DeltaCVP to predict the hemodynamic response to a fluid challenge.
1,295 citations
"Inferior vena cava diameter and col..." refers methods in this paper
...There has been recent criticism of using CVP to estimate fluid responsiveness, arguing that CVP, whether as an absolute value or in terms of changes in response to fluid, does not correlate with ventricular volume or volume-responsiveness(16,17)....
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...Therefore, CVP measurement is still a useful tool for guiding hemodynamic therapy and remains the standard of care in shock management(17,22)....
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TL;DR: Although there was no significant difference in the primary outcome of 60-day mortality, the conservative strategy of fluid management improved lung function and shortened the duration of mechanical ventilation and intensive care without increasing nonpulmonary-organ failures.
1,186 citations
"Inferior vena cava diameter and col..." refers background in this paper
...For example, a randomized trial comparing different fluid management strategies in patients with acute lung injury also included filling pressure in the algorithms(20), and the algorithm of the early goal-directed therapy for the treatment of sepsis included CVP(21)....
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TL;DR: IVC respiratory collapse on echocardiography is easily imaged and can be used to estimate RA pressure, and a caval index greater than or equal to 50% indicates RA pressure less than 10 mm Hg, and caval indexes less than 50% indicate RA pressure greater than and equal to 10 Hg.
Abstract: To evaluate a simple noninvasive means of estimating right atrial (RA) pressure, the respiratory motion of the inferior vena cava (IVC) was analyzed by 2-dimensional echocardiography in 83 patients. Expiratory and inspiratory IVC diameters and percent collapse (caval index) were measured in subcostal views within 2 cm of the right atrium. Parameters were correlated with RA pressure by flotation catheter within 24 hours of the echocardiogram (38 were simultaneous). Correlations between RA pressure (range 0 to 28 mm Hg), expiratory and inspiratory diameters and caval index were 0.48, 0.71 and 0.75, respectively. Of 48 patients with caval indexes less than 50%, 41 (89%) had RA pressure greater than or equal to 10 mm Hg (mean +/- standard deviation, 15 +/- 6), while 30 of 35 patients (86%) with caval indexes greater than or equal to 50% had RA pressure less than 10 mm Hg (mean 6 +/- 5). Sensitivity and specificity for discrimination of RA pressure greater than or equal to or less than 10 mm Hg were maximized at the 50% level of collapse. Thus, IVC respiratory collapse on echocardiography is easily imaged and can be used to estimate RA pressure. A caval index greater than or equal to 50% indicates RA pressure less than 10 mm Hg, and caval indexes less than 50% indicate RA pressure greater than or equal to 10 Hg.
942 citations
"Inferior vena cava diameter and col..." refers methods in this paper
...Several authors measure both the inspiratory and expiratory diameters of the IVC and use them to calculate a so-called caval or collapsibility index(24)....
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TL;DR: Normal healthy volunteers demonstrate a lack of correlation between initial central venous pressure/pulmonary artery occlusion pressure and both end-diastolic ventricular volume indexes and stroke volume index, suggesting a more universal phenomenon that includes normal subjects.
Abstract: of normal saline loading correlated well with initial stroke volume index and changes in stroke volume index, respectively. The relationship between left ventricular end-diastolic volume index and stroke volume index was confirmed in group 2 subjects using mathematically independent techniques to measure these variables. In addition, initial central venous pressure, right ventricular end-diastolic volume index, pulmonary artery occlusion pressure, and left ventricular end-diastolic volume index failed to correlate significantly with changes in cardiac performance in response to saline infusion in group 1 subjects. Conclusions: Normal healthy volunteers demonstrate a lack of correlation between initial central venous pressure/pulmonary artery occlusion pressure and both end-diastolic ventricular volume indexes and stroke volume index. Similar results are found with respect to changes in these variables following volume infusion. In contrast, initial enddiastolic ventricular volume indexes and changes in end-diastolic ventricular volume indexes in response to saline loading correlate strongly with initial and postsaline loading changes in cardiac performance as measured by stroke volume index. These data suggest that the lack of correlation of these variables in specific patient groups described in other studies represents a more universal phenomenon that includes normal subjects. Neither central venous pressure nor pulmonary artery occlusion pressure appears to be a useful predictor of ventricular preload with respect to optimizing cardiac performance. (Crit Care Med 2004; 32:691‐699)
743 citations
"Inferior vena cava diameter and col..." refers methods in this paper
...There has been recent criticism of using CVP to estimate fluid responsiveness, arguing that CVP, whether as an absolute value or in terms of changes in response to fluid, does not correlate with ventricular volume or volume-responsiveness(16,17)....
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