Inferior Vena Cava Index Research Articles

Prognostic significance of inferior vena cava volume defined by initial polytrauma CT-imaging: single-center experience of a level-1 trauma center

BackgroundThe significance of computed tomography (CT)-based volume measurement of the inferior vena cava (IVC) in the treatment and prognosis of trauma patients is not yet fully understood. The conflicting results that have been reported may be attributable to differences in injury severity and the use of different measurement methods, including IVC index and volumetry. The purpose of this study was to determine the relationship between IVC volume and red blood cell (RBC) transfusion and mortality in intubated trauma patients who were stable enough for initial CT imaging.MethodsA retrospective analysis was conducted on all consecutive trauma patients who underwent emergency tracheal intubation and mechanical ventilation before initial whole-body CT imaging at a level-1 trauma center over a 12-year period (2008–2019). The IVC volume was determined on initial trauma CT and included in multivariable models with demographic and diagnostic data. Associations of overall RBC transfusion, massive transfusion, 24-h mortality, and 30-day mortality were assessed using logistic regression analyses and Cox proportional hazard models.ResultsA total of 438 patients (75.3% male) with a median age of 50 years, and a median injury severity score (ISS) of 26 points were included in the analysis. Most of the patients (97.5%) had suffered from blunt trauma mechanisms. Median IVC volume was 36.25 cm3, and RBC transfusion and massive transfusion were performed in 197 and 90 patients, respectively. The 24-h and 30-day mortality rates were 7.3% and 23.3%, respectively. VCI volume was found to be independently associated with the necessity of RBC transfusion and 24-h mortality (OR 0.98, 95% CI 0.96–0.99, p = 0.01 and HR 0.96, 95% CI 0.93–0.99, p = 0.025, respectively), while associations with massive transfusion and 30-day mortality were not statistically significant in multivariable analyses.ConclusionInitial IVC volume may serve as a predictor of patients at risk for overall RBC transfusion requirements and 24-h mortality, suggesting the possibility of its diagnostic efficacy in short-term outcomes. Further studies are needed to confirm these findings.

Correlation of Internal Jugular Vein and Inferior Vena Cava Collapsibility Index with Direct Central Venous Pressure Measurement in Critically-ill Patients: An Observational Study.

Prompt assessments and quick replacement of intravascular fluid are critical steps to resuscitate hypovolemic patients. Intravascular volume assessment by direct central venous pressure (CVP) measurement is an invasive, time-consuming, and labor-intensive procedure. Nowadays, bedside ultrasound-guided volume assessment of the internal jugular vein (IJV) or inferior vena cava (IVC) is commonly employed as a proxy for direct CVP.Therefore, we examined the strength of association between CVP and collapsibility index (CI) of the IJV and IVC for evaluating the volume status of critically ill patients. Bedside USG-guided A-P diameter and cross-sectional area of the right IJV and IVC were measured, and their corresponding collapsibility indices were deduced. The results of the IJV and IVC indices were correlated with CVP. About 60 out of 70 enrolled patients were analyzed. The baseline clinical parameters of patients are shown in Table 1. For CSA and AP diameter, the correlations between CVP and IJV-CI at 0° were r = -0.107 (p = 0.001) and r = -0.092 (p = 0.001). Correlations between CVP and IJV-CI at 30° for CSA and diameter, however, were (r = -0.109, p = 0.001) and (r = -0.117, p = 0.001), respectively. Table 2 depicts the correlation between CVP and IVC-CI r = -0.503, p = 0.001 for CSA and r = -0.452, p = 0.001 for diameter. The IVC and IJV collapsibility indices can be used in place of invasive CVP monitoring to assess fluid status in critically ill patients. Kumar A, Bharti AK, Hussain M, Kumar S, Kumar A. Correlation of Internal Jugular Vein and Inferior Vena Cava Collapsibility Index with Direct Central Venous Pressure Measurement in Critically-ill Patients: An Observational Study. Indian J Crit Care Med 2024;28(6):595-600.

Usefulness of Non-Invasive Parameters (Inferior Vena Cava Diameter, Inferior Vena Cava Collapsibility, Inferior Vena Cava-Aortic Ratio) for Hemodynamic Monitoring in Critically Ill Children: A Systematic Review.

Volume measurement in critically ill children can be conducted using invasive procedure such as Central Venous Pressure (CVP), or non-invasive procedure such as measurement of Inferior Vena Cava (IVC) indices using ultrasonography. However, their accuracy and efficacy are still under scrutiny. We aim to compare CVP and IVC indices as non-invasive parameters in assessing volume status in critically ill children. We conducted a systematic review based on literature searching from four electronic databases which were PubMed, Cochrane, ScienceDirect, SpringerLink with keywords: "CENTRAL VENOUS PRESSURE", "INFERIOR VENA CAVA DIAMETER", "INFERIOR VENA CAVA COLLAPSIBILITY", "INFERIOR VENA CAVA AORTIC-RATIO", "VOLUME STATUS", "FLUID STATUS", "CRITICAL ILL", "CHILDREN", and "PEDIATRICS". We included relevant studies in English published from 2000 to 2023 on critically ill children aged 0-18 years. Comparison between CVP and IVC indices was resumed. Eight articles were included in this study. Majority of the studies showed a consistent correlation between CVP and IVC indices. IVC-CI was the most common parameter evaluated in the included studies. There was moderate to strong correlations using IVC-CI and IVC-DI, and moderate correlation using IVC-Ao ratio. We found that non-invasive tools might have a potential role to measure volume in critically ill children equals to CVP. Further high-quality and longitudinal studies are needed to validate these findings and to establish a clear guideline for the non-invasive tool to be used in daily clinical practice.

A preoperative ultrasound-based protocol for optimisation of fluid therapy to prevent early intraoperative hypotension: a randomised controlled study

BackgroundIntraoperative hypotension is a risk factor for postoperative complications. Preoperative dehydration is a major contributor, although it is difficult to estimate its severity. Point-of-care ultrasound offers several potential methods, including measurements of the inferior vena cava. The addition of lung ultrasound may offer a safety limit. We aimed to evaluate whether the implication of an ultrasound-based preoperative fluid therapy protocol can decrease the incidence of early intraoperative hypotension.MethodsRandomised controlled study in a tertiary university department involves elective surgical patients of ASA 2–3 class, scheduled for elective major abdominal surgery under general anaesthesia with intubation. We randomised 40–40 patients; 38–38 were available for analysis. Conventional fluid therapy was ordered on routine preoperative visits. Ultrasound-based protocol evaluated the collapsibility index of inferior vena cava and lung ultrasound profiles. Scans were performed twice: 2 h and 30 min before surgery. A high collapsibility index (≥ 40%) indicated a standardised fluid bolus, while the anterior B-profile of the lung ultrasound contraindicated further fluid. The primary outcome was the incidence of postinduction and early intraoperative (0–10 min) hypotension (MAP < 65 mmHg and/or ≥ 30% of decrease from baseline). Secondary endpoints were postoperative lactate level, urine output and lung ultrasound score at 24 h.ResultsThe absolute criterion of postinduction hypotension was fulfilled in 12 patients in the conventional group (31.6%) and 3 in the ultrasound-based group (7.9%) (p = 0.0246). Based on composite criteria of absolute and/or relative hypotension, we observed 17 (44.7%) and 7 (18.4%) cases, respectively (p = 0.0136). The incidence of early intraoperative hypotension was also lower: HR for absolute hypotension was 2.10 (95% CI 1.00–4.42) in the conventional group (p = 0.0387). Secondary outcome measures were similar in the study groups.ConclusionWe implemented a safe and effective point-of-care ultrasound-based preoperative fluid replacement protocol into perioperative care.Trial registrationThe study was registered to ClinicalTrials.gov on 10/12/2021, registration number: NCT05171608 (registered prospectively on 10/12/2021).

Value of inferior vena cava diameter and inferior vena cava collapse index in the evaluation of peripartum volume: A prospective cohort study

ObjectiveThe maternal intravascular volume status assessed during and after gestation is valuable but challenging due to the influence of the substantial adaptive cardiovascular changes during pregnancy. The present study aimed to investigate the changes in the size of inferior vena cava (IVC) diameter and collapse index (IVC-CI) during perinatal delivery and whether it is affected by the change in intravascular volume during delivery. Study designA total of 31 full-term, singleton, and cephalic delivery women delivered by vagina with an estimated blood loss of >500 mL measured longitudinally between September 2019 and September 2020 in the Department of Obstetrics and Gynecology of The Third Hospital in China. The end-expiratory (IVCe) and end-inspiratory (IVCi) diameters of the inferior vena cava were measured at the first, second, and third stages of labor (T1, T2, and T3, respectively) and postpartum haemorrhage ≥500 mL (T4 and after rapid rehydration 500 mL (T5). The collapse index of IVC was calculated, and blood pressure and heart rate were measured. ResultsIVCe and IVC-CI changed significantly in a volume-dependent manner during the perinatal period (T1–T5; P < 0.05). IVCe narrowed significantly with volume reduction (after postpartum hemorrhage) and widened significantly with volume increase (after volume resuscitation). IVC-CI increases significantly with decreased capacity and decreases significantly with increased capacity. ConclusionThe width and collapse index of IVC reflect the circulatory volume changes during the parturient’s perinatal period with postpartum hemorrhage.

Volume Status Assessment by Lung Ultrasound in End-Stage Kidney Disease: A Systematic Review.

Lung ultrasound is a noninvasive bedside technique that can accurately assess pulmonary congestion by evaluating extravascular lung water. This technique is expanding and is easily available. Our primary outcome was to compare the efficacy of volume status assessment by lung ultrasound with clinical evaluation, echocardiography, bioimpedance, or biomarkers. The secondary outcomes were all-cause mortality and cardiovascular events. We conducted a MEDLINE literature search for observational and randomized studies with lung ultrasound in patients on maintenance dialysis. From a total of 2363 articles, we included 28 studies (25 observational and 3 randomized). The correlation coefficients were pooled for each variable of interest using the generic inverse variance method with a random effects model. Among the clinical parameters, New York Heart Association Functional Classification of Heart Failure status and lung auscultation showed the highest correlation with the number of B-lines on ultrasound, with a pooled r correlation coefficient of .57 and .36, respectively. Among echocardiographic parameters, left ventricular ejection fraction and inferior vena cava index had the strongest correlation with the number of B-lines, with a pooled r coefficient of .35 and .31, respectively. Three randomized studies compared a lung ultrasound-guided approach with standard of care on hard clinical endpoints. Although patients in the lung ultrasound group achieved better decongestion and blood pressure control, there was no difference between the 2 management strategies with respect to death from any cause or major adverse cardiovascular events. Lung ultrasound may be considered for the identification of patients with subclinical volume overload. Trials did not show differences in clinically important outcomes. The number of studies was small and many were of suboptimal quality. The included studies were heterogeneous and of relatively limited quality.

Application Value of Emergency Bedside Echocardiography in Early Warning of Acute and Severe Shock and Clinical Classification.

Objective A case-control study was conducted to explore the application value of emergency bedside echocardiography in early warning of acute and severe shock and clinical classification. Methods A total of 135 critically ill patients admitted to ICU from August 2019 to November 2020 were divided into shock group (n = 53) and nonshock group (n = 82) according to the occurrence of shock. The internal diameter index of inferior vena cava was measured and recorded by bedside ultrasound in patients with shock before and after treatment and in patients without shock. Shock index and inferior vena cava diameter deformation index (SCI) were calculated according to the results. The diagnostic time and curative effect of different ultrasonic examination methods for the types of shock were compared and analyzed. Results At admission, the maximum and minimum ventilation of inferior vena cava in patients without shock were higher than those in the shock group, and the internal diameter deformation index of inferior vena cava in the shock group was higher than that in the shock group (P < 0.05). In the shock group, IVCmax and IVCmin before and after treatment were higher than those before resuscitation, while SCI was lower than that before resuscitation. The results of ROC curve analysis showed that SCI and IVCmin were significantly better than IVCmax and IVCmin in predicting shock area and slightly better than IVCmin. There was significant difference in diagnosis time between the two groups (P < 0.05). The specificity, positive predictive value, and negative predictive value of emergency ultrasound diagnosis were lower than those of clinical diagnosis (P < 0.05). The sensitivity, specificity, positive predictive value, and negative predictive value of emergency ultrasound diagnosis were lower than those of clinical diagnosis (P < 0.05). The sensitivity and positive predictive value of the emergency ultrasound group were higher than those of the routine ultrasound group (P < 0.05). The diagnosis rate of shock type AUC in the emergency ultrasound group was 0.854, and the diagnostic value was high. Conclusion IVCmax, IVCmin, and SCI obtained by bedside ultrasound have certain clinical significance for the diagnosis and treatment of shock. Emergency bedside ultrasound examination and measurement of shock patients are helpful to quickly evaluate and identify the types of early shock.

IVC measurement for the noninvasive evaluation of central venous pressure.

Central venous pressure (CVP) is one of only a handful of variables that can be used to assess a patient's volume status to attempt to optimize stroke volume. The gold standard method for assessing CVP is though pulmonary artery catheterization, which is invasive and risks severe complications such as pneumothorax and cardiac conduction abnormalities. Current noninvasive methods for estimating CVP such as jugular venous pressure assessment are imperfect with wide inter-examiner variability. The inferior vena cava (IVC) is a highly compliant vessel that uniquely does not constrict in response to hypovolemia, making it an ideal, noninvasive surrogate for the estimation of CVP. A range of IVC indices including minimum and maximum IVC diameter and fraction of IVC collapse with inspiration (known as collapsibility index) have been studied with highly variable results that range from excellent to poor correlation between these values and CVP. Despite this inconsistency in findings, multiple schemes have been proposed to attempt to estimate CVP from IVC measurements, but when prospectively tested, none has been shown to be accurate. Since the most recent 2015 American Society of Echocardiography guidelines, multiple studies have identified unique ways of improving the accuracy of IVC measurement, which could translate into better CVP estimation. The goal of this review is to summarize the many, often conflicting studies that exist in this area, and provide recommendations for future studies based on our findings.

Application value of bedside ultrasound for assessing volume responsiveness in patients with septic shock

Background/Aim. Septic shock is a serious complication that can occur as consequence of infection. As the effective circulating blood volume is of vital importance in these cases, it is very important to keep track of this parameter constantly. The aim of this study was to explore the application value of bedside ultrasound for assessing volume responsiveness in patients with septic shock. Methods. A total of 102 patients with septic shock were selected. The volume load (VL) test was performed, and based on the results of the test, the patients were divided into the response group that had an increase in stroke volume (?SV ) ? 15% and non-response group (?SV &lt; 15%). Hemodynamic parameters were compared before and after the test. The correlation between ?SV and each hemodynamic index was explored by Pearson?s analysis. The receiver operating characteristic (ROC) curve was plotted. Results. There were 54 patients in response group and 48 patients in non-response group. Before VL test, retro-hepatic inferior vena cava (IVC) distensibility index (?IVC1), respiratory variation in IVC index (?IVC2), respiratory variation in aortic blood flow peak velocity index (?VpeakAO), respiratory variation in brachial artery blood flow peak velocity index (?VpeakBA) and respiratory variation in common femoral artery blood flow peak velocity index (?VpeakCFA) were all higher in response group than those in non-response group (p &lt; 0.05), while heart rate (HR), mean arterial pressure (MAP) and central venous pressure (CVP) were similar (p &gt; 0.05). After VL test, response group had significantly decreased HR, ?IVC1, ?IVC2, ?VpeakAO, ?VpeakBA and ?VpeakCFA, and increased MAP and CVP (p &lt; 0.05), while non-response group had significantly decreased CVP (p &lt; 0.05) and no significant changes in other indices. ?IVC1, ?IVC2, ?VpeakAO, ?VpeakBA and ?VpeakCFA significantly correlated with ?SV ( r= 0.589, r = 0.647, r = 0.697, r = 0.621, r = 0.766, p &lt; 0.05), but there was no correlation between CVP and ?SV (r = -0.345, p &gt; 0.05). The areas under the curves of ?IVC1, ?IVC2, ?VpeakAO, ?VpeakBA and ?VpeakCFA for predicting volume responsiveness were 0.839, 0.858, 0.878, 0.916 and 0.921, respectively, which were significantly larger than that of CVP (0.691), indicating higher sensitivity and specificity. Conclusion. Bedside ultrasound monitoring of ?IVC, ?VpeakAO, ?VpeakBA and ?VpeakCFA can better assess the volume responsiveness in patients with septic shock.

ANOVA-Based Analysis of Early Blood Transfusions on Hemodynamics with Severely Injured Trauma Using Bedside Ultrasound Imaging.

The focus of the study was to quantitatively analyze the influence of early massive blood transfusions (MBTs) on the hemodynamics and prognostic living quality of patients with severely injured trauma. 114 patients with severely injured trauma were enrolled into MBT group (67 cases) and nonmassive blood transfusions (NBT) group (47 cases) according to whether they accepted MBTs within 24 hours after the admission. All patients had bedside ultrasound technology scanning. Furthermore, the indexes were calculated for inferior vena cava (IVC), peripheral arteries, and heart. The prognostic deaths were recorded. It was found that, in the MBT group, the mortality was lower (7.55% vs. 24.23%) (P < 0.05), and these indexes were higher for the IVC expansion (IVCE), the respiration variation index (RVI) of IVC (ΔIVC2), the peak flow velocity RVI of brachial artery (ΔVpeakBA), femoral artery (ΔVpeakFA), left ventricular outflow tract (ΔVpeakL), and aorta (ΔVpeakAO), as well as peak flow velocity time integral RVI of aorta (ΔVTIAO) (P < 0.05). In conclusion, early MBTs can elevate survival rate and prognostic living quality and alleviate the atrophy degree of IVC, peripheral artery, and blood vessel of patients with severely injured trauma. Furthermore, bedside ultrasound scanning demonstrated superb capabilities in quantitatively displaying hemodynamics and outcomes of MBTs of patients with severely injured trauma.

Delta Inferior Vena Cava Index Correlated with Mean Arterial Pressure (MAP) in Spinal Anesthesia

Background: Spinal anesthesia has become an alternative to general anesthesia. However, spinal anesthesia has the most common side effects including, bradycardia and hypotension. The aim of this study was to determine the relationship between changes in the inferior vena cava index (delta inferior vena cava index) to changes in mean arterial pressure in spinal anesthesia. Methods: This study was an observational pre-post test study in thirty-two patients who received spinal anesthesia. The inferior vena cava index (inferior vena cava collectibility index and caval-aorta index) was measured before and after spinal anesthesia (5 and 10 minutes after onset). Data were analyzed using the Kolmogorov Smirnov test, Shapiro-Wilk test, T-test, and correlation test with α=5% Result: There was a significant difference in mean arterial pressure (MAP), delta inferior vena cava collectibility index (D-IVC-CI), and delta caval-aorta index (D-CAo-I) before and after spinal anesthesia. D-IVC-CI and D-CAo-I are significantly correlated with MAP. The correlation between D-IVC-CI and MAP had R = -0.371 (P &lt;0.05) at 5 minutes post-anesthesia, while D-CAo-I and MAP had R = 0.472 (P &lt;0.05) at 10 minutes post-anesthesia. Conclusion: The delta inferior vena cava index is correlated with the mean arterial pressure (MAP) value in spinal anesthesia.

Point-of-care ultrasound to assess volume status and pulmonary oedema in malaria patients

PurposeFluid management is challenging in malaria patients given the risks associated with intravascular fluid depletion and iatrogenic fluid overload leading to pulmonary oedema. Given the limitations of the physical examination in guiding fluid therapy, we evaluated point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) and lungs as a novel tool to assess volume status and detect early oedema in malaria patients.MethodsTo assess the correlation between IVC and lung ultrasound (LUS) indices and clinical signs of hypovolaemia and pulmonary oedema, respectively, concurrent clinical and sonographic examinations were performed in an observational study of 48 malaria patients and 62 healthy participants across age groups in Gabon.ResultsIVC collapsibility index (CI) ≥ 50% on enrolment reflecting intravascular fluid depletion was associated with an increased number of clinical signs of hypovolaemia in severe and uncomplicated malaria. With exception of dry mucous membranes, IVC-CI correlated with most clinical signs of hypovolaemia, most notably sunken eyes (r = 0.35, p = 0.0001) and prolonged capillary refill (r = 0.35, p = 0.001). IVC-to-aorta ratio ≤ 0.8 was not associated with any clinical signs of hypovolaemia on enrolment. Among malaria patients, a B-pattern on enrolment reflecting interstitial fluid was associated with dyspnoea (p = 0.0003), crepitations and SpO2 ≤ 94% (both p < 0.0001), but not tachypnoea (p = 0.069). Severe malaria patients had increased IVC-CI (p < 0.0001) and more B-patterns (p = 0.004) on enrolment relative to uncomplicated malaria and controls.ConclusionIn malaria patients, POCUS of the IVC and lungs may improve the assessment of volume status and detect early oedema, which could help to manage fluids in these patients.

The Flatness Index of Inferior Vena Cava can be an Accurate Predictor for Hypovolemia in Multi-Trauma Patients.

Shock is the leading cause of death in multi-trauma patients and must be detected at an early stage to improve prognosis. Many parameters are used to predict clinical condition and outcome in trauma. Computed tomography (CT) signs of hypovolemic shock in trauma patients are not clear yet, requiring further research. The flatness index of inferior vena cava (IVC) is a helpful method for this purpose. This is a prospective, cross-sectional study which included adult multi-trauma patients (>18 years) who were admitted to the emergency department (ED) and underwent a thoraco-abdominal CT from 2017 through 2018. The main objective of this study was to investigate whether the flatness index of IVC can be used to determine the hypovolemic shock at an early stage in multi-trauma patients, and to establish its relations with shock parameters. The patients' demographic features, trauma mechanisms, vitals, laboratory values, shock parameters, and clinical outcome within 24 hours of admission were recorded. Total of 327 (229 males with an average age of 40.9 [SD = 7.93]) patients were included in the study. There was no significant difference in the flatness index of IVC within genders (P = .134) and trauma mechanisms (P = .701); however, the flatness index of IVC was significantly higher in hypotensive (systolic blood pressure [SBP] ≤90 mmHg and/or diastolic blood pressure [DBP] ≤60 mmHg; P = .015 and P = .019), tachycardic (P = .049), and hypoxic (SpO2 ≤%94; P <.001) patients. The flatness index of IVC was also higher in patients with lactate ≥ 2mmol/l (P = .043) and patients with Class III hemorrhage (P = .003). A positive correlation was determined between lactate level and the flatness index of IVC; a negative correlation was found between Glasgow Coma Scale (GCS) and Revised Trauma Score (RTS) with the flatness index of IVC (for each of them, P <.05). The flatness index of IVC may be a useful method to determine the hypovolemic shock at an early stage in multi-trauma patients.

The relationship between collapsibility index of inferior vena cava and hypotension after spinal anesthesia

Objectives: Hypotension is a common complication of spinal anesthesia. Imaging of inferior vena cava (IVC) and measurement of the IVC-collapsibility index (IVC-CI) by ultrasonography (USG) has been a widely used non-invasive, easy and reliable method for measurement of the fluid imbalance. In the present study, we aimed to investigate the predictive ability of the maximum IVC diameter (dIVCmax) and IVC-CI for hypotension after spinal anesthesia. Methods: The study was designed as prospective and observational. One hundred thirty-two patients aged 18-75 years with ASA I-II underwent inguinal hernia surgery with spinal anesthesia and recruited to the study. Maximum and minimum (dIVCmin) IVC diameters were measured. IVC-CI (%) was quantified according to the formula of [(dIVCmax - dIVCmin)/dIVKmax] × 100%. Results: The patients were grouped as hypotensive and non-hypotensive. In fifty-seven patients of 120 cases (47.5%), hypotension has emerged following spinal anesthesia. No significant differences in dIVCmax and IVC-CI were recorded between the study groups (p &amp;gt; 0.05). There were significant inverse correlation between age and IVC-CI. Significant positive correlation between the lowest values of the systolic arterial pressure, diastolic arterial pressure, mean arterial pressure and IVC-CI and significant positive correlation between dIVCmax and diastolic blood pressure, maximum and minimum values of the mean arterial pressure. Conclusions: We found that dIVCmax and IVC-CI values measured before spinal anesthesia were not sufficient parameters enough to predict hypotension after spinal anesthesia. Further studies investigating the IVC measurements under spinal anesthesia together with dynamic hemodynamic monitorization modalities are needed.

Correlation of inferior vena cava diameter and collapsibility index with central venous pressure in shocked patients

Objective The aim was to determine the correlation of the caval index, inferior vena cava (IVC) diameter, and central venous pressure (CVP) in shocked patients in the emergency room. Background Assessment of intravascular volume is important in shocked patients. It can be measured through many techniques, among those include CVP, collapsibility index, and diameter of IVC. Patients and methods This was a prospective and cross-sectional study and included 100 patients treated at the Emergency Department of Menoufia University Hospital. They were selected according to certain inclusion and exclusion criteria with already inserted central venous catheter and were measured for CVP, and concomitantly the IVC diameter was measured with ultrasound using M-mode to measure the expiratory and inspiratory diameter and collapsibility index of the IVC, and then the patients were divided into three groups according to the CVP, with CVP less than 10, CVP 10–15 and CVP more than 15. Results Among the 100 patients enrolled, the median age was 56.01 ± 20.92 years. The correlation of the CVP measurement with the ultrasound IVC caval index was r= −0.911 (P < 0.001), with the expiratory IVC diameter was r = 0.703 (P < 0.001), and with the inspiratory IVC diameter was r = 0.875 (P < 0.001). The sensitivity and specificity of the caval index showed that the cutoff points were 50, 40, and 20 at CVP levels 10, 10–15, and 15 cm H2 O, respectively. Conclusion This study found that in shocked patients there is a good correlation between CVP and collapsibility index, as well as with inspiratory and expiratory diameter of IVC.

Iso-Oncotic Albumin Mitigates Brain and Kidney Injury in Experimental Focal Ischemic Stroke.

Background: There is widespread debate regarding the use of albumin in ischemic stroke. We tested the hypothesis that an iso-oncotic solution of albumin (5%), administered earlier after acute ischemic stroke (3 h), could provide neuroprotection without causing kidney damage, compared to a hyper-oncotic albumin (20%) and saline.Objective: To compare the effects of saline, iso-oncotic albumin, and hyper-oncotic albumin, all titrated to similar hemodynamic targets, on the brain and kidney.Methods: Ischemic stroke was induced in anesthetized male Wistar rats (n = 30; weight 437 ± 68 g) by thermocoagulation of pial blood vessels of the primary somatosensory, motor, and sensorimotor cortices. After 3 h, animals were anesthetized and randomly assigned (n = 8) to receive 0.9% NaCl (Saline), iso-oncotic albumin (5% ALB), and hyper-oncotic albumin (20% ALB), aiming to maintain hemodynamic stability (defined as distensibility index of inferior vena cava <25%, mean arterial pressure >80 mmHg). Rats were then ventilated using protective strategies for 2 h. Of these 30 animals, 6 were used as controls (focal ischemic stroke/no fluid).Results: The total fluid volume infused was higher in the Saline group than in the 5% ALB and 20% ALB groups (mean ± SD, 4.3 ± 1.6 vs. 2.7 ± 0.6 and 2.6 ± 0.5 mL, p = 0.03 and p = 0.02, respectively). The total albumin volume infused (g/kg) was higher in the 20% ALB group than in the 5% ALB group (1.4 ± 0.6 vs. 0.4 ± 0.2, p < 0.001). Saline increased neurodegeneration (Fluoro-Jade C staining), brain inflammation in the penumbra (higher tumor necrosis factor-alpha expression), and blood-brain barrier damage (lower gene expressions of claudin-1 and zona occludens-1) compared to both iso-oncotic and hyper-oncotic albumins, whereas it reduced the expression of brain-derived neurotrophic factor (a marker of neuroregeneration) compared only to iso-oncotic albumin. In the kidney, hyper-oncotic albumin led to greater damage as well as higher gene expressions of kidney injury molecule-1 and interleukin-6 than 5% ALB (p < 0.001).Conclusions: In this model of focal ischemic stroke, only iso-oncotic albumin had a protective effect against brain and kidney damage. Fluid therapy thus requires careful analysis of impact not only on the brain but also on the kidney.

Hemodynamic response in cirrhotic patients with transjugular intrahepatic portosystemic shunt

Objective: To discuss the effects of transjugular intrahepatic portosystemic shunt (TIPS) procedure on hemodynamics in cirrhotic patients. Methods: A total of 23 cirrhotic patients for TIPS insertion were enrolled from January 2018 to October 2018. Serum N-terminal pro-B-type natriuretic peptide (NT-proBNP), transthoracic echocardiography and non-invasive cardiac output measurement based on impedance cardiogram were carried out before and 24h, 1 month, 6 months after TIPS in order to observe cardiac function and hemodynamic changes after TIPS. Results: Significant increases in right atrial area [(17.2±4.0) cm(2) vs. (15.0±3.4) cm(2), P<0.05], right ventricular area [(15.1±3.8) cm(2) vs. (13.7±3.5) cm(2), P<0.05] and left ventricular volume [(97.4±21.5) ml vs. (91.1±22.7) ml, P<0.05] were observed 24 h after TIPS. These changes were accompanied with significant reduction in collapsible index of inferior vena cava [(20.7± 8.1)% vs. (28.6±11.3)%, P<0.01] and elevation in pulmonary arterial systolic pressure [(36.0±8.4) mmHg (1 mmHg=0.133 kPa) vs. (31.8±5.4) mmHg, P<0.01]. There also existed significantly elevated serum NT-proBNP [(551.2±325.1) ng/L vs. (124.2±94.4) ng/L, P<0.01], cardiac output [(5.82±0.96) L/min vs. (5.12±1.28) L/min, P<0.01], cardiac index [(3.47±0.64) L·min(-1)·m(-2) vs. (3.05±0.78) L·min(-1)·m(-2), P<0.01], early diastolic filling rate [(59.0±14.3)% vs. (54.5±11.0)%, P<0.05], and reduced systemic vascular resistance index (SVRi) [(1 798.4±357.3) dyne·s·cm(-5)·m(-2) vs. (2 195.7±508.7) dyne·s·cm(-5)·m(-2), P<0.01] 24 h after TIPS. At the end of 6-month follow-up, all these parameters, but not SVRi, returned towards baseline values. Moreover, peak early to late diastolic tissue velocity ratio at the level of lateral mitral annulus (E'/A') was significantly higher at the end of 6-month follow-up than that at baseline (1.06±0.32 vs. 0.90±0.45, P<0.05). Neither the right ventricular fractional area changes nor the left ventricular ejection fractions during the follow-up period were different from those at baseline (P>0.05). Conclusion: Cirrhotic patients who had no cardiovascular pathologies had adequate adaptation and good compensation ability to reach a new hemodynamic homeostasis for the increased volume load after TIPS insertion.

Role of Point-of-Care Lung and Inferior Vena Cava Ultrasound in Clinical Decisions for Patients Presenting to the Emergency Department With Symptoms of Acute Decompensated Heart Failure.

This prospective study was performed to evaluate the diagnostic role of point-of-care lung ultrasound (LUS) and inferior vena cava (IVC) ultrasound in patients with acute decompensated heart failure (ADHF). A prospective cohort study was conducted between January 2018 and November 2018 on patients with a diagnosis of ADHF in the emergency department (ED). On admission, LUS findings, inspiratory and expiratory IVC diameters, and the inferior vena cava collapsibility index (IVCCI) were obtained. After therapeutic interventions, third-hour changes in LUS and the IVC index and the treatment response were assessed. Eighty patients were enrolled. Forty-six (58%) patients had an ejection fraction (EF) greater than 40%, and 34 (42%) had an EF of less than 40%. Significant differences were detected between the admission and third-hour inspiratory IVC diameter, expiratory IVC diameter, and IVCCI (P = .001). There was no correlation between the EF and inspiratory IVC diameter (r = -0.03; P = .976), expiratory IVC diameter (r = -109; P = .336), or IVCCI (r = -0.72; P = .523) and between the B-type natriuretic peptide level and inspiratory IVC diameter (r = -0.58; P = .610), expiratory IVC diameter (r = -0.33; P = .774), or IVCCI (r = -0.78; P = .493) either. A comparison of admission and third-hour numbers of B-lines on LUS imaging showed a significant decrease in the number of B-lines in all zones at the end of 3 hours (P = .001). A significant difference existed between the hospitalized and discharged patients with respect to IVC diameters and number of B-lines. In the ED setting, an assessment of B-lines and measurement of IVC diameters are better markers than the B-type natriuretic peptide level, EF, or chest x-ray for diagnosis of ADHF and can be used to make decisions for hospitalization or discharge from the ED.

Distensibility Index of Inferior Vena Cava and Pulse Pressure Variation as Predictors of Fluid Responsiveness in Mechanically Ventilated Shocked Patients

Background: Currently, pulse pressure variation (PPV) is considered the gold standard dynamic variable for predicting fluid responsiveness. Distensibility index of inferior vena cava (dIVC) is also considered a good predictor of fluid responsiveness. However, information from literature comparing the performance of both variables is still patchy and insufficient. Therefore, we aimed to investigate the accuracy of dIVC and PPV in predicting fluid responsiveness and compare the predictive power of both techniques. Methods: We conducted our study in shocked patients receiving mechanical ventilation requiring fluid challenge. Hemodynamic variables, such as PPV and dIVC, were recorded before and after fluid challenges. Fluid responders were identified when cardiac output increased more than 15% after the first fluid challenge. Only the non-responders received a second fluid challenge (SFC) to define delayed responders. Results: A total of 38 shocked patients were enrolled in this study. Twenty-one patients (55.3%) were fluid responders. The area under the receiver operating characteristic (AUROC) curve of PPV was 0.78 ± 0.08 with a best cutoff of 10.5 (sensitivity: 76.2%; specificity: 70.6%). The AUROC curve of dIVC was 0.75 ± 0.07, and the best cutoff value to predict fluid responsiveness was 16.5% with a sensitivity of 71.43% and specificity of 76.5%. Four patients from the non-responder group became responders after the SFC. No statistically significant difference was observed between the predictive performance of PPV and dIVC. Conclusions: Our findings indicate that the performance of PPV for predicting fluid responsiveness was similar to that of dIVC. PPV and dIVC are moderately predictive of fluid responsiveness.

Chest Ultrasound as a New Tool for Assessment of Volume Status in Hemodialysis Patients.

Accurate assessment of volume status (VS) in hemodialysis (HD) patients is challenging. The use of chest ultrasound (CUS) for detection of extravascular lung water has recently gained wide acceptance. The aim of this study was to evaluate the use of CUS in VS assessment in HD patients in comparison to clinical and inferior vena cava (IVC) indices and to assess their relation with volume displacement after ultrafiltration. This prospective cohort study was carried out on 38 patients on regular HD. VS was assessed using a 13-point clinical score, and IVC indices and CUS score were measured pre- and post-ultrafiltration. Correlation between these parameters and with ultrafiltration volume was tested. There was a statistically significant reduction in post-ultrafiltration CUS score and the 13-point clinical score (P < 0.01). Moreover, reduction in all the IVC indices (inspiratory and expiratory diameters and collapsing index) was detected, but did not reach statistical significance (P = 0.185, P = 0.296, and P = 0.194, respectively). CUS score had statistically significant correlations with ultrafiltration volume and New York Heart Association classes (P < 0.001 and <0.001, respectively). Neither clinical signs nor IVC indices can be used independently for the assessment of VS in HD patients. CUS is a useful guide in VS assessment, and we recommend its routine use in the management of HD patients. Concomitant use of bio- impedance analysis (BIA) may be needed in addition to CUS for more accurate assessment of VS in HD patients.