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      Inferior Vena Cava Measurement with Ultrasound: What Is the Best View and Best Mode?

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          Abstract

          Introduction

          Intravascular volume status is an important clinical consideration in the management of the critically ill. Point-of-care ultrasonography (POCUS) has gained popularity as a non-invasive means of intravascular volume assessment via examination of the inferior vena cava (IVC). However, there are limited data comparing different acquisition techniques for IVC measurement by POCUS. The goal of this evaluation was to determine the reliability of three IVC acquisition techniques for volume assessment: sub-xiphoid transabdominal long axis (LA), transabdominal short axis (SA), and right lateral transabdominal coronal long axis (CLA) (aka “rescue view”).

          Methods

          Volunteers were evaluated by three experienced emergency physician sonographers (EP). Gray scale (B-mode) and motion-mode (M-mode) diameters were measured and IVC collapsibility index (IVCCI) calculated for three anatomic views (LA, SA, CLA). For each IVC measurement, we calculated descriptive statistics, intra-class correlation coefficients (ICC), and two-way univariate analyses of variance.

          Results

          EPs evaluated 39 volunteers, yielding 351 total US measurements. Measurements of the three views had similar means (LA 1.9 ± 0.4cm; SA 1.9 ± 0.4cm; CLA 2.0 ± 0.5cm). For B-Mode, LA had the highest ICC (0.86, 95% CI [0.76–0.92]) while CLA had the poorest ICC (0.74, 95% CI [0.56–0.85]). ICCs for all M-mode IVCCI were low. Significant interaction effects between anatomical view and EP were observed for B-mode and M-mode measurements. Post-hoc analyses revealed difficulty in consistent view acquisition between EPs.

          Conclusion

          Inter-rater reliability of the IVC by EPs was highest for B-mode LA and poorest for all M-Mode IVC collapsibility indices (IVCCI). These results suggest that B-mode LA holds the most promise to deliver reliable measures of IVC diameter. Future studies may focus on validation in a clinical setting as well as comparison to a reference standard.

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          The respiratory variation in inferior vena cava diameter as a guide to fluid therapy.

          Marc Feissel, Frederic Michard, Jean-Pierre Faller … (2004)
          To investigate whether the respiratory variation in inferior vena cava diameter (DeltaD(IVC)) 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 DeltaD(IVC) 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 or =15% (responders). Before volume loading, the DeltaD(IVC) 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% DeltaD(IVC) cut-off value allowed identification of responders with positive and negative predictive values of 93% and 92%, respectively. Analysis of DeltaD(IVC) is a simple and non-invasive method to detect fluid responsiveness in mechanically ventilated patients with septic shock.
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            Reappraisal of the use of inferior vena cava for estimating right atrial pressure.

            J Brennan, John Blair, Sascha Goonewardena … (2007)
            Estimation of right atrial pressure (RAP) using echocardiographic measurement of the inferior vena caval (IVC) size along with its respirophasic variation is commonly performed despite the paucity of data that critically evaluates this technique. In this study, we systematically evaluated echocardiographic imaging of the IVC for estimation of RAP in 102 patients undergoing right heart catheterization. This study established cut-off values using receiver operating characteristic analysis for 8 different IVC parameters and then prospectively tested these parameters for their ability to predict an elevated RAP. The IVC size cutoff with optimum predictive use for RAP above or below 10 mm Hg was 2.0 cm (sensitivity 73% and specificity 85%) and the optimal IVC collapsibility cutoff was 40% (sensitivity 73% and specificity 84%). Traditional classification of RAP into 5-mm Hg ranges based on IVC size and collapsibility performed poorly (43% accurate) and a new classification scheme is proposed.
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              Ultrasonographic measurement of the respiratory variation in the inferior vena cava diameter is predictive of fluid responsiveness in critically ill patients: systematic review and meta-analysis.

              Zhongheng Zhang, Xiao Xu, Sheng Ye … (2014)
              Respiratory variation in the inferior vena cava (ΔIVC) has been extensively studied with respect to its value in predicting fluid responsiveness, but the results are conflicting. This systematic review was aimed at investigating the diagnostic accuracy of ΔIVC in predicting fluid responsiveness. Databases including Medline, Embase, Scopus and Web of Knowledge were searched from inception to May 2013. Studies exploring the diagnostic performance of ΔIVC in predicting fluid responsiveness were included. To allow for more between- and within-study variance, a hierarchical summary receiver operating characteristic model was used to pool the results. Subgroup analyses were performed for patients on mechanical ventilation, spontaneously breathing patients and those challenged with colloids and crystalloids. A total of 8 studies involving 235 patients were eligible for analysis. Cutoff values of ΔIVC varied across studies, ranging from 12% to 40%. The pooled sensitivity and specificity in the overall population were 0.76 (95% confidence interval [CI]: 0.61-0.86) and 0.86 (95% CI: 0.69-0.95), respectively. The pooled diagnostic odds ratio (DOR) was 20.2 (95% CI: 6.1-67.1). The diagnostic performance of ΔIVC appeared to be better in patients on mechanical ventilation than in spontaneously breathing patients (DOR: 30.8 vs. 13.2). The pooled area under the receiver operating characteristic curve was 0.84 (95% CI: 0.79-0.89). Our study indicates that ΔIVC measured with point-of-care ultrasonography is of great value in predicting fluid responsiveness, particularly in patients on controlled mechanical ventilation and those resuscitated with colloids.
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                Author and article information

                Journal
                Journal ID (nlm-ta): West J Emerg Med
                Journal ID (iso-abbrev): West J Emerg Med
                Journal ID (publisher-id): WestJEM
                Title: Western Journal of Emergency Medicine
                Publisher: Department of Emergency Medicine, University of California, Irvine School of Medicine
                ISSN (Print): 1936-900X
                ISSN (Electronic): 1936-9018
                Publication date (Print): April 2017
                Publication date (Electronic): 24 February 2017
                Volume: 18
                Issue: 3
                Pages: 496-501
                Affiliations
                The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio
                Author notes
                Address for Correspondence: Nathan M. Finnerty, MD, The Ohio State University College of Medicine, Department of Emergency Medicine, 750. Prior Hall, 376 W 10th Avenue, Columbus, Ohio 43210. Email: nathan.finnerty@ 123456osumc.edu .
                Article
                Publisher ID: wjem-18-496
                DOI: 10.5811/westjem.2016.12.32489
                PMC ID: 5391901
                PubMed ID: 28435502
                SO-VID: e347d99b-4f84-4046-84d0-5864a619d207
                Copyright © Copyright: © 2017 Finnerty et al.
                License:

                This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/licenses/by/4.0/

                History
                Date received : 15 September 2016
                Date revision received : 26 November 2016
                Date accepted : 12 December 2016
                Categories
                Subject: Technology in Emergency Medicine
                Subject: Original Research

                ScienceOpen disciplines: Emergency medicine & Trauma
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma

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