Brief ReportThe role of inferior vena cava diameter in volume status monitoring; the best sonographic measurement method?☆
Introduction
Assessing and monitoring intravascular volume status are critical parts of the management of critically ill patients. Currently, the volume status is assessed by physical examination, vital sign assessment, measurement of biochemical markers, tissue perfusion, and central venous pressure (CVP), and sonographic assessment of inferior vena cava (IVC) diameter [1]. Physical examination, one of the simplest and most rapid methods among them, is not reliable for assessment of intravascular volume status [2], [3]. Blood pressure, on the other hand, may remain relatively normal until 30% of total body water is lost, which is sufficient for multiple-organ dysfunction [4]. Therefore, various advanced methods including CVP monitorization, pulmonary artery catheterization, esophageal catheterization, transesophageal echocardiography, and transthoracic echocardiography (TTE) are sometimes needed. Unfortunately, most of these methods require special knowledge and skills, and they cause significant time loss for the patients in the emergency department. Moreover, there is no consensus for the indications of the traditional invasive monitorization methods [5], [6]. All these invasive methods are a source of potential morbidity and mortality. Noninvasive methods have thus recently become more popular [7]. Among them, IVC diameter ultrasound measurement (IVC-USG) has been reported to reliably reflect volume status [8], [9], [10], [11], [12], [13], [14], although there have also been studies suggesting otherwise [15], [16], [17]. Most important of all, CVP is considered as gold standard when the relationship between the IVC diameter and intravascular volume is studied [18], [19], [20], [21]. However, the accuracy of CVP measurement in reflecting volume status is controversial [22], [23], [24]. A total of 803 patient meta-analyses containing 24 studies demonstrated that there is only a weak correlation between CVP and volume status [23]. This has caused the value of CVP to be debated. Studies on the relationship between IVC diameter and volume status in volunteer blood donors without taking CVP into account have yielded varying results [8], [16]. These data suggest that there is an ongoing need for studies that examine the relationship between IVC and volume status.
The first objective of the present study was to determine whether there was a relationship between sonographically measured IVC diameter and intravascular volume status. The second objective was to find out which of the IVC measurement methods was most successful in reflecting the accurate volume status.
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Study design and setting
We designed a prospective, observational, single-center study with a before-and-after design to determine the relationship between fluid replacement and IVC diameter. The study design dictated repeated measurements of IVC diameter after each 500-mL saline replacement. This study was conducted after it was approved by the education planning committee of the hospital. Each study subject gave a written informed consent.
The study was conducted in the emergency department of a training and research
Results
This study included 35 consecutive patients in total who presented to the emergency department within the specified time window. Four patients (11.4 %) were excluded because they lacked the required optimal echogenity for IVC-USG and TTE. Three patients (8.5 %) were excluded from the final data analysis owing to severe TR on TTE. The remaining 28 patients were included in the final statistical analysis. None of the patients were intubated and received vasoactive treatment. The demographic
Discussion
Inferior vena cava is a high compliance vessel whose dimensions and dynamics are altered by total body water and respiration [26]. Nett et al administered norepinephrine to patients with low total body fluid and blood pressure. They observed that IVC size remained constant despite increased blood pressure, suggesting that IVC diameter was more related to volume status than SBP [28]. However, a meta-analysis dated 2011 indicated a moderate level of evidence for measuring IVC diameter in
Limitation
This study is a single-center study with a relatively small sample size.
B-mode and M-mode measurements might have been affected by each other since they were carried out in a successive manner. To minimize this bias, video recordings were made first in both modes, followed by carrying out measurements from the video recordings.
This study excluded patients with severe TR. Therefore, this method is not applicable to patients with severe TR.
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Agreement between subcostal and transhepatic longitudinal imaging of the inferior vena cava for the evaluation of fluid responsiveness: A systematic review
2022, Journal of Critical CareCitation Excerpt :Pronounced lateral IVC displacement during respiration is clinically relevant since the migration of the plane may simulate false reduction in IVC size. For this reason, some authors suggested that M-mode may be inaccurate because the movement of the diaphragm can cause caudal IVC displacement [34] and 2-D mode may seem advisable as it can adjust the measurement site of IVC during the respiratory cycle [34,35]. Whether these differences between M- and 2-D modes are of clinical significance remains debated [35].
Respiratory variability of inferior vena cava at different mechanical ventilator settings
2021, American Journal of Emergency MedicineCitation Excerpt :Likewise, Sefidbakht et al. used M-mode to predict shock in trauma patients and reported successful results [23]. Celebi Yamanoglu et al. demonstrated the most effective method was the M-mode inspiratory diameter measurement to predict fluid responsiveness [24]. Currently, there is no standardized approach.
Inferior vena cava, abdominal aorta, and IVC-to-aorta ratio in healthy Caucasian children: Ultrasound Z-scores according to BSA and age
2019, Journal of CardiologyCitation Excerpt :A positive correlation of the mean IVC diameter with the central venous pressure (CVP) has been demonstrated [3,5,24]. The increasing IVC mean diameter seems to predict a higher risk of heart failure while a contraction of intravascular volume is proved to result in measurable decreases in the diameter [31–35]. However, many hemodynamic and instrumental factors influence the IVC measure and in the literature there is much controversy about its use [36].
Assessment of hemodynamic response to fluid resuscitation of patients with intra-abdominal sepsis in low- and middle-income countries
2017, Journal of Surgical ResearchCitation Excerpt :As would be expected, the mean UOP increased with time and with the amount of IVFs administered. Similarly, the mean IVC-CI decreased over time with IVFs administration, and these findings are similar with those from the study by Celebi Yamanoglu et al., and Barbier C et al.9,10,14 IVC-CI detected response to fluid resuscitation 2 h earlier than the measurement of UOP (P < 0.001).
Point-of-Care Ultrasound in Austere Environments: A Complete Review of Its Utilization, Pitfalls, and Technique for Common Applications in Austere Settings
2017, Emergency Medicine Clinics of North America
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Prior presentations: Poster Presentation at the 1. International Critical Care and Emergency Medicine Congress, Novenber 2013, Istanbul.