Does ultrasonography of the inferior vena cava predict volume responsiveness? n n
Date First Published:
January 9, 2010
Last Updated:
July 7, 2010
Report by:
Maude St-Onge and Marc-Charles Parent, MSO: Emergency medicine resident, PhD student in experimental medicine; MCP: FRCP emergency (Université Laval)
Search checked by:
Maude St-Onge, Université Laval
Three-Part Question:
In [critically ill adult patients], does [ultrasonography of the inferior vena cava] predict [volume responsiveness]?
Clinical Scenario:
A 75 years old man presents at the ED with a pneumonia and severe sepsis. The patient is also known for cardiac failure. After being intubated and having received few liters of fluids, the patient does not seem to get better. The physician wonders if the ultrasonography of the inferior vena cava would help him to know if the patient is fluid-responsive or not.
Search Strategy:
No best bet on this topic was found.
Ovid MEDLINE(R) 1950 to November week 4 2009 : 171
EMBASE 1950 to November week 4 2009 via Elsevier: 277
Cochrane library to November week 4 : 0
Ovid MEDLINE(R) 1950 to November week 4 2009 : 171
EMBASE 1950 to November week 4 2009 via Elsevier: 277
Cochrane library to November week 4 : 0
Search Details:
Medline search :
(("Vena Cava, Inferior" AND and ultrasonography) OR ("Inferior Vena Cava" AND and ultrasonography) OR ("Inferior Vena Cava" AND and ultrasound) OR ("Vena Cava, Inferior" AND and ultrasound)) AND ((Fluid therapy/methods*) OR (hemodynamics*) OR (shock/therapy*) OR (shock fluid resuscitation) OR (fluid responsiveness) OR (fluid resuscitation) OR (volume resuscitation) OR (volume responsiveness))
(("Vena Cava, Inferior" AND and ultrasonography) OR ("Inferior Vena Cava" AND and ultrasonography) OR ("Inferior Vena Cava" AND and ultrasound) OR ("Vena Cava, Inferior" AND and ultrasound)) AND ((Fluid therapy/methods*) OR (hemodynamics*) OR (shock/therapy*) OR (shock fluid resuscitation) OR (fluid responsiveness) OR (fluid resuscitation) OR (volume resuscitation) OR (volume responsiveness))
Outcome:
Inclusion criteria:
- Population: Critically ill adult patients
- Intervention: Ultrasonography of the inferior vena cava before volume expansion
- Studies: Meta-analysis, systematic reviews, RCT, observational studies
- Outcomes: Prediction of increase in cardiac index after volume expansion
Exlcusion criteria: Pediatrics, animal subjects, prehospital setting
- Population: Critically ill adult patients
- Intervention: Ultrasonography of the inferior vena cava before volume expansion
- Studies: Meta-analysis, systematic reviews, RCT, observational studies
- Outcomes: Prediction of increase in cardiac index after volume expansion
Exlcusion criteria: Pediatrics, animal subjects, prehospital setting
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients Barbier C, Loubières Y, Schmit C, Hayon J, Ricôme JL, Jardin F, Veillard-Baron A 2004 France | 23 adult patients with acute circulatory failure (systolic arterial pressure below 90mmHg and/or perfusion of vasopressor amines) related to sepsis and mechanically ventilated (tidal volume 8,5+/-1,5ml/kg, PEEP 4+/-2) because of an acute lung injury. | Prospective observational study | Fluid responsiveness define as 15% or more increase in cardiac index after a 30 min 7ml/kg volume expansion using plasma expander (4% modified fluid gelatin) | -tOf all parameter changes (heart rate, systolic arterial pressure, cardiac index, central venous pressure, dose of vasopressor and distensibility index (dIVC), only dIVC differed significantly between the two groups -tUsing a threshold distensibility index (dIVC) of the IVC of 18%, responders and non-responders were discriminated with 90% sensitivity and 90% specificity -tA strong relation (r=0,9) was observed between dIVC at baseline and the cardiac index increase following blood volume expansion -tN.B.: dIVC = IVC maximum diameter on inspiration (Dmax) – IVC minimum diameter on expiration (Dmin) /Dmin) | -tAbdominal pressure was not measure for all patients. -tFirst observer was not blind to fluid administration. -tIntra- and inter-observer variabilities in the measurement of IVC diameter were 6,3+/-8 and 8.7+/-9%, respectively. -tTraining of the observer was not describe. -tCardiac index was calculated from the right ventricular outflow tract. -tFluid used was not normal saline or ringer lactate. -tThree patients were excluded because of their poor response to echocardiography. -tOther treatments were not standardized. -tdIVC was not compared to delta of pulse pressure or superior vena cava ultrasonography as a marker of fluid responsiveness. -tTricuspid regurgitation and vena cava backward flow may be observed in mechanically ventilated patients which can affecte the size of the IVC and then RCIVCD. The impact of this regurgitation can be avoided if RCIVCD measurement is made at end-diastole period, but this method was not used. |
| The repiratory variation in inferior vena cava diameter as a guide to fluid therapy Feissel M, Michard F, Faller JP, Teboul JL 2004 France | 39 mechanically ventilated (tidal volume 8-10 ml/kg) patients with septic shock | Prospective observational study | Fluid responsiveness define as 15% or more increase in cardiac index after a 20 min 8ml/kg volume expansion using plasma expander (6% hydroxyethylstarch modified fluid gelatin) | -tΔIVC is more elevated (25 +/- 15%) in fluid responsive patient compare to non fluid responsive patients (6 +/- 4%) -tA linear correlation exists between the ΔIVC and the pourcentage of cardiac index augmentation (r=0,82) -tIVC max and IVC min showed less correlation (r = 0,44 for IVC max and r = 0,58 for IVC min) -tΔIVC of 12% or more predicts fluid responsiveness with a PPV of 93% and NPV of 92% -tN.B.: ΔIVC = IVC max-IVCmin/IVCmax+IVCmin/2 | -tAbdominal pressure was not measure. -tBlinding is not describe. -tIntra- and inter-observer variabilities in the measurement of IVC diameter is unknown. -tTraining of the observer was not describe. -tFluid used was not normal saline or ringer lactate. -tΔIVC was not compared to delta of pulse pressure or superior vena cava ultrasonography as a marker of fluid responsiveness. |
Author Commentary:
Population
To use ultrasonography of the inferior vena cava, the patient must be ventilated in the volum-controlled mode and strictly adapted too the ventilator. Pratically, patients should be deeply sedated or paralyzed to preclude any voluntary ventilatory efforts. The patient should be in sinus rythm. Respiratory variation of the vena cava diameter should be cautiously interpreted when small tidal volumes and high level of PEEP are used. Also, clinical situations associated with increased intra-abdominal pressure or elevated right atrial pressure may potentially invalidate the use of respiratory variation in the IVC diameter to predict fluid responsiveness.
Intervention
Barbier and Feissel used a sub-xyphoidal long axis view method and measured the IVC in M-mode. The training required to be able to use ultrasonography of the inferior vena cava is unknown.
Comparaison
Superior vena cava with trans-oesophageal ultrasonography and delta of pulse pressure are other options described in the litterature. Ultrasonography of the inferior vena cava was not compared to those two other measures.
Outcomes
Those results from prospective observational studies were done in small very specific cohorts. Other studies are required to evaluate the external validity.
To use ultrasonography of the inferior vena cava, the patient must be ventilated in the volum-controlled mode and strictly adapted too the ventilator. Pratically, patients should be deeply sedated or paralyzed to preclude any voluntary ventilatory efforts. The patient should be in sinus rythm. Respiratory variation of the vena cava diameter should be cautiously interpreted when small tidal volumes and high level of PEEP are used. Also, clinical situations associated with increased intra-abdominal pressure or elevated right atrial pressure may potentially invalidate the use of respiratory variation in the IVC diameter to predict fluid responsiveness.
Intervention
Barbier and Feissel used a sub-xyphoidal long axis view method and measured the IVC in M-mode. The training required to be able to use ultrasonography of the inferior vena cava is unknown.
Comparaison
Superior vena cava with trans-oesophageal ultrasonography and delta of pulse pressure are other options described in the litterature. Ultrasonography of the inferior vena cava was not compared to those two other measures.
Outcomes
Those results from prospective observational studies were done in small very specific cohorts. Other studies are required to evaluate the external validity.
Bottom Line:
Ultrasonography of the inferior vena cava (dIVC or ΔIVC) predicts volume responsiveness in intubated critically ill adult patients strictly adapted too ventilator.
Level of Evidence:
Level 2: Studies considered were neither 1 or 3
References:
- Barbier C, Loubières Y, Schmit C, Hayon J, Ricôme JL, Jardin F, Veillard-Baron A. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients
- Feissel M, Michard F, Faller JP, Teboul JL. The repiratory variation in inferior vena cava diameter as a guide to fluid therapy