The BUDDY (Bedside Ultrasound to Detect Dehydration in Youth) study.

Joshua Jauregui,Esther Choo,Sachita P Shah,Adam C Levine,Daniel Nelson,Branden Stearns,Otto Liebmann

doi:10.1186/s13089-014-0015-z

Abstract

BackgroundPrior research suggests that the ratio of the ultrasound-measured diameter of the inferior vena cava to the aorta correlates with the level of dehydration in children. This study was designed to externally validate this and to access the accuracy of the ultrasound measured inspiratory IVC collapse and physician gestalt to predict significant dehydration in children in the emergency department.MethodsWe prospectively enrolled a non-consecutive cohort of children ≤18 years old. Patient weight, ultrasound measurements of the IVC and Ao, and physician gestalt were recorded. The percent weight change from presentation to discharge was used to calculate the degree of dehydration. A weight change of ≥5% was considered clinically significant dehydration. Receiver operating characteristic (ROC) curves were constructed for each of the ultrasound measurements and physician gestalt. Sensitivity (SN) and specificity (SP) were calculated based on previously established cutoff points of the IVC/Ao ratio (0.8), the IVC collapsibility index of 50%, and a new cut off point of IVC collapsibility index of 80% or greater. Intra-class correlation coefficients were calculated to assess the degree of inter-rater reliability between ultrasound observers.ResultsOf 113 patients, 10.6% had significant dehydration. The IVC/Ao ratio had an area under the ROC curve (AUC) of 0.72 (95% CI 0.53 to 0.91) and, with a cutoff of 0.8, produced a SN of 67% and a SP of 71% for the diagnosis of significant dehydration. The IVC collapsibility index of 50% had an AUC of 0.58 (95% CI 0.44 to 0.72) and, with a cutoff of 80% collapsibility, produced a SN of 83% and a SP of 42%. The intra-class correlation coefficient was 0.83 for the IVC/Ao ratio and 0.70 for the IVC collapsibility. Physician gestalt had an AUC of 0.61 (95% CI 0.44 to 0.78) and, with a cutoff point of 5, produced a SN of 42% and a SP of 65%.ConclusionsThe ultrasound-measured IVC/Ao ratio is a modest predictor of significant dehydration in children. The inspiratory IVC collapse and physician gestalt were poor predictors of the actual level of dehydration in this study.

Highlights

Prior research suggests that the ratio of the ultrasound-measured diameter of the inferior vena cava to the aorta correlates with the level of dehydration in children
The diagnostic options available to clinicians hoping to discern mild from significant, or moderate or severe, dehydration include non-invasive measures such as physician gestalt and clinical scales derived from signs and symptoms, invasive hemodynamic monitoring, laboratory values, and bedside ultrasound techniques newly described in the literature
Clinical scales such as the World Health Organization (WHO) scale, the Gorelick scale, and the clinical dehydration scale (CDS) known as the Parkin scale have been studied in a handful of trials, which show that none of these scales perform with a high measure of sensitivity to detect clinically significant dehydration in the pediatric emergency department population [8,9,10,11,12,13,14,15]

Summary

Introduction

Prior research suggests that the ratio of the ultrasound-measured diameter of the inferior vena cava to the aorta correlates with the level of dehydration in children. The diagnostic options available to clinicians hoping to discern mild from significant, or moderate or severe, dehydration include non-invasive measures such as physician gestalt and clinical scales derived from signs and symptoms, invasive hemodynamic monitoring, laboratory values, and bedside ultrasound techniques newly described in the literature Clinical scales such as the World Health Organization (WHO) scale, the Gorelick scale, and the clinical dehydration scale (CDS) known as the Parkin scale have been studied in a handful of trials, which show that none of these scales perform with a high measure of sensitivity to detect clinically significant dehydration in the pediatric emergency department population [8,9,10,11,12,13,14,15]. Adult literature suggests CVP may not be a reliable indicator of volume depletion as the cause of hypotension and suggest CVP is unhelpful in predicting which patients will be ‘fluid responders’ and which patients may need other methods of blood pressure support [18,19]

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Conclusion