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      Can Nephrologists Use Ultrasound to Evaluate the Inferior Vena Cava A Cross-Sectional Study of the Agreement between a Nephrologist and a Cardiologist

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          Abstract

          Background/Aims: The costs and the need for a specialist impair the implementation of ultrasonography for evaluating the inferior vena cava (IVC) to assess the volemic status in hemodialysis patients. We investigated whether a nephrologist with limited ultrasound training can accurately assess the IVC in patients undergoing hemodialysis. Methods: A cardiologist and a nephrologist consecutively measured the indexed IVC expiratory diameter (VCDi) and the IVC collapsibility index (IVCCI) of 52 patients during hemodialysis sessions. In protocol I, the nephrologist used a regular ultrasound system (RUS) and the cardiologist used a cardiovascular ultrasound equipment; in protocol II, the machines were interchanged. Pearson and kappa coefficients and the interexaminer agreement by the Bland-Altman method were calculated. Results: The VCDi measurements showed a strong correlation in both protocols (r = 0.88 and 0.84 in protocols I and II, respectively). The volemic classifications were excellent in protocol I (kappa = 0.82 and 0.93 by VCDi and IVCCI, respectively) and substantial in protocol II (kappa = 0.77 and 0.75 by VCDi and IVCCI, respectively). The interexaminer agreement on the VCDi measurements was very good in both protocols. Conclusions: Ultrasound evaluation of the IVC can be performed by nephrologists using an RUS to assess the volemic status in hemodialysis patients.

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          Most cited references 26

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          Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in estimating intravascular volume status: correlations with CVP.

          Volume status assessment is an important aspect of patient management in the surgical intensive care unit (SICU). Echocardiologist-performed measurement of IVC collapsibility index (IVC-CI) provides useful information about filling pressures, but is limited by its portability, cost, and availability. Intensivist-performed bedside ultrasonography (INBU) examinations have the potential to overcome these impediments. We used INBU to evaluate hemodynamic status of SICU patients, focusing on correlations between IVC-CI and CVP. Prospective evaluation of hemodynamic status was conducted on a convenience sample of SICU patients with a brief (3 to 10 minutes) INBU examination. INBU examinations were performed by noncardiologists after 3 hours of didactics in interpreting and acquiring two-dimensional and M-mode images, and > or =25 proctored examinations. IVC-CI measurements were compared with invasive CVP values. Of 124 enrolled patients, 101 had CVP catheters (55 men, mean age 58.3 years, 44.6% intubated). Of these, 18 patients had uninterpretable INBU examinations, leaving 83 patients with both CVP monitoring devices and INBU IVC evaluations. Patients in three IVC-CI ranges ( 0.60) demonstrated significant decrease in mean CVP as IVC-CI increased (p = 0.023). Although 40% of this group had a CVP >12 mmHg. Conversely, >60% of patients with IVC-CI >0.6 had CVP 0.60) collapsibility ranges. Additional studies are needed to confirm and expand on findings of this study.
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            Evaluation of size and dynamics of the inferior vena cava as an index of right-sided cardiac function.

            To define normal criteria of size and dynamics of the inferior vena cava (IVC) and its clinical value in assessing right-sided cardiac function, 2-dimensional (2-D) and M-mode echocardiography (echo) were performed in 175 subjects, who were classified into 3 groups: group 1-80 normal subjects; group IIA--65 patients with documented right-sided cardiac disease, and group IIB--30 patients with cardiac disease but no right-sided abnormality. The IVC was adequately imaged in 175 of 185 subjects (95%). There was good correlation between M-mode and 2-D echo (r = 0.84) and long- and short-axis (r = 0.88) measurements. The IVC diameter during expiration was: group 1-9 to 28 mm (mean 18.2 +/- 4.6); group IIA--15 to 40 mm (mean 23.1 +/- 4.8) and group IIB-8-24 mm (mean 15.6 +/- 3.7). Collapsibility index (inspiratory decrease in diameter) was: group I-37 to 100% (mean 55.8 +/- 15.9); group IIA--0 to 39% (mean 13.5 +/- 10.5); and group IIB--44 to 100% (mean 60.4 +/- 13.1). A and V waves could be measured in 120 of 151 cases (79%). Both A and V waves were less than 125% of its diameter in group I. The A wave was absent in 34 patients; 30 (88%) were in atrial fibrillation. Among 8 patients with tricuspid regurgitation, 5 (63%) had V waves greater than 125%. There was no correlation between diameter or collapsibility index and age, sex, rhythm or body surface area.(ABSTRACT TRUNCATED AT 250 WORDS)
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              Handcarried ultrasound measurement of the inferior vena cava for assessment of intravascular volume status in the outpatient hemodialysis clinic.

              Accurate intravascular volume assessment is critical in the treatment of patients who receive chronic hemodialysis (HD) therapy. Clinically assessed dry weight is a poor surrogate of intravascular volume; however, ultrasound assessment of the inferior vena cava (IVC) is an effective tool for volume management. This study sought to determine the feasibility of using operators with limited ultrasound experience to assess IVC dimensions using hand-carried ultrasounds (HCU) in the outpatient clinical setting. The IVC was assessed in 89 consecutive patients at two outpatient clinics before and after HD. Intradialytic IVC was recorded during episodes of hypotension, chest pain, or cramping. High-quality IVC images were obtained in 79 of 89 patients. Despite that 89% of patients presented at or above dry weight, 39% of these patients were hypovolemic by HCU. Of the 75% of patients who left HD at or below goal weight, 10% were still hypervolemic by HCU standards. Hypovolemic patients had more episodes of chest pain and cramping (33 versus 14%, P = 0.06) and more episodes of hypotension (22 versus 3%, P = 0.02). The clinic with a higher prevalence of predialysis hypovolemia had significantly more intradialytic adverse events (58 versus 27%; P = 0.01). HCU measurement of the IVC is a feasible option for rapid assessment of intravascular volume status in an outpatient dialysis setting by operators with limited formal training in echocardiography. There is a poor relationship between dry weight goals and IVC collapsibility. Practice variation in the maintenance of volume status is correlated with significant differences in intradialysis adverse events.
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                Author and article information

                Journal
                NNE
                NNE
                10.1159/issn.1664-5529
                Nephron Extra
                S. Karger AG
                1664-5529
                2014
                January – April 2014
                30 April 2014
                : 4
                : 1
                : 82-88
                Affiliations
                aDivision of Nephrology, Federal University of Juiz de Fora, and bNúcleo Interdisciplinar de Estudos e Pesquisas em Nefrologia (NIEPEN), Juiz de Fora, cClinical Department, Faculty of Medicine of Barbacena (FAME), and dPró-Renal Center of Renal Diseases and Dialysis Unit, Barbacena, Brazil; eWorld Interactive Network Focused on Critical Ultrasound (WINFOCUS), Milan, Italy
                Author notes
                *Hélady Sanders-Pinheiro, Rua Benjamin Constant, 1044/1001, Juiz de Fora, Minas Gerais 36015-400 (Brazil), E-Mail helady.sanders@ufjf.edu.br
                Article
                362170 PMC4036136 Nephron Extra 2014;4:82-88
                10.1159/000362170
                PMC4036136
                24926312
                © 2014 S. Karger AG, Basel

                Open Access License: This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) ( http://www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 2, Tables: 3, Pages: 7
                Categories
                Original Paper

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