Variations Of Inferior Vena Cava Research Articles

Assessment of fluid responsiveness using pulse pressure variation, stroke volume variation, plethysmographic variability index, central venous pressure, and inferior vena cava variation in patients undergoing mechanical ventilation: a systematic review and meta-analysis

ImportanceManeuvers assessing fluid responsiveness before an intravascular volume expansion may limit useless fluid administration, which in turn may improve outcomes.ObjectiveTo describe maneuvers for assessing fluid responsiveness in mechanically ventilated patients.RegistrationThe protocol was registered at PROSPERO: CRD42019146781.Information sources and searchPubMed, EMBASE, CINAHL, SCOPUS, and Web of Science were search from inception to 08/08/2023.Study selection and data collectionProspective and intervention studies were selected.Statistical analysisData for each maneuver were reported individually and data from the five most employed maneuvers were aggregated. A traditional and a Bayesian meta-analysis approach were performed.ResultsA total of 69 studies, encompassing 3185 fluid challenges and 2711 patients were analyzed. The prevalence of fluid responsiveness was 49.9%. Pulse pressure variation (PPV) was studied in 40 studies, mean threshold with 95% confidence intervals (95% CI) = 11.5 (10.5–12.4)%, and area under the receiver operating characteristics curve (AUC) with 95% CI was 0.87 (0.84–0.90). Stroke volume variation (SVV) was studied in 24 studies, mean threshold with 95% CI = 12.1 (10.9–13.3)%, and AUC with 95% CI was 0.87 (0.84–0.91). The plethysmographic variability index (PVI) was studied in 17 studies, mean threshold = 13.8 (12.3–15.3)%, and AUC was 0.88 (0.82–0.94). Central venous pressure (CVP) was studied in 12 studies, mean threshold with 95% CI = 9.0 (7.7–10.1) mmHg, and AUC with 95% CI was 0.77 (0.69–0.87). Inferior vena cava variation (∆IVC) was studied in 8 studies, mean threshold = 15.4 (13.3–17.6)%, and AUC with 95% CI was 0.83 (0.78–0.89).ConclusionsFluid responsiveness can be reliably assessed in adult patients under mechanical ventilation. Among the five maneuvers compared in predicting fluid responsiveness, PPV, SVV, and PVI were superior to CVP and ∆IVC. However, there is no data supporting any of the above mentioned as being the best maneuver. Additionally, other well-established tests, such as the passive leg raising test, end-expiratory occlusion test, and tidal volume challenge, are also reliable.

The effect of laparoscopic pneumoperitoneum on patient’s respiratory variation of inferior vena cava and stroke volume index: A randomized controlled study

Background: The establishment of pneumoperitoneum has impacts on patient’s cardiovascular function. In this study, the respiratory variation of inferior vena cava (IVC), stroke volume (SV) index, and other parameters was monitored to determine how the pneumoperitoneum affects the patient’s hemodynamic and acknowledge how to resolve it. Materials and Methods: Fifty-five patients were randomly divided into Group A (8 mmHg), Group B (10 mmHg), Group C (12 mmHg), Group D (14 mmHg), and Group E (12 mmHg, infusion with 7 mL/kg crystalloid solution). The parameters including IVC variability, SV index, mean artery pressure (MAP), heart rate (HR), cardiac output index (CI), and airway pressure were measured, to compare the changes before and after pneumoperitoneum. Results: Among Group A, Group B, Group C, and Group D, there were no significant differences in patients’ prepneumoperitoneum information. Compare with prepneumoperitoneum, the difference in IVC variability, SV index, MAP, HR, CI, and airway pressure was statistically significant (P < 0.05). After the establishment of pneumoperitoneum, the difference in IVC variability, SV index, and airway pressure among Group A, Group B, Group C, and Group D was statistically significant (P < 0.05). Compare with Group C, the change rates of IVC variability, SV index, MAP, HR, and CI were smaller in Group E (P < 0.05). Conclusion: The establishment of pneumoperitoneum could increase the patient’s IVC variability and reduce SV index, and with the increase of pressure, IVC variability had an increasing trend, SV index had a decreasing trend. Fluid transfusion could reduce the relative influence of the pneumoperitoneum.

Impact of Age-Related Change in Caval Flow Ratio on Hepatic Flow Distribution in the Fontan Circulation.

The Fontan operation is a palliative technique for patients born with single ventricle heart disease. The superior vena cava (SVC), inferior vena cava (IVC), and hepatic veins are connected to the pulmonary arteries in a total cavopulmonary connection by an extracardiac conduit or a lateral tunnel connection. A balanced hepatic flow distribution (HFD) to both lungs is essential to prevent pulmonary arteriovenous malformations and cyanosis. HFD is highly dependent on the local hemodynamics. The effect of age-related changes in caval inflows on HFD was evaluated using cardiac magnetic resonance data and patient-specific computational fluid dynamics modeling. SVC and IVC flow from 414 patients with Fontan were collected to establish a relationship between SVC:IVC flow ratio and age. Computational fluid dynamics modeling was performed in 60 (30 extracardiac and 30 lateral tunnel) patient models to quantify the HFD that corresponded to patient ages of 3, 8, and 15 years, respectively. SVC:IVC flow ratio inverted at ≈8 years of age, indicating a clear shift to lower body flow predominance. Our data showed that variation of HFD in response to age-related changes in caval inflows (SVC:IVC, 2, 1, and 0.5 corresponded to ages, 3, 8, and 15+, respectively) was not significant for extracardiac but statistically significant for lateral tunnel cohorts. For all 3 caval inflow ratios, a positive correlation existed between the IVC flow distribution to both the lungs and the HFD. However, as the SVC:IVC ratio changed from 2 to 0.5 (age, 3-15+) years, the correlation's strength decreased from 0.87 to 0.64, due to potential flow perturbation as IVC flow momentum increased. Our analysis provided quantitative insights into the impact of the changing caval inflows on Fontan's long-term HFD, highlighting the importance of SVC:IVC variations over time on Fontan's long-term hemodynamics. These findings broaden our understanding of Fontan hemodynamics and patient outcomes.

Percentages and Gender Distribution of Anatomic Variations of Inferior Vena Cava, Renal Veins, and Posterior Lumbar Tributaries of the Left Renal Vein Left Renal Vein Drainage Variations

Objective: The aim of this study was to investigate percentages and gender distribution of the variations of the inferior vena cava (IVC), renal veins, and posterior lumbar tributaries of the left renal vein (LRV).
 Materials and Methods: For this cross sectional observational study, the computed tomography (CT) images of 1949 patients were evaluated retrospectively.
 Results: In the present study, percentages of double IVC, left IVC, and IVC interruption with azygos continuation were 0.5%, 0.2%, and 0.1%, respectively; circumaortic left renal vein (CLRV) was 6% and retroaortic left renal vein (RLRV) was 4.2%. Multiple renal vein variations were 24.1% on the right, but none on the left. Posterior lumbar tributaries of the renal veins were 0.15% on the right and 48% on the left. There was no difference between genders in terms of LRV and IVC variations. While the incidence of multiple right renal veins was statistically significantly higher in male patients compared to female patients (p = 0.045), the opposite was true for the posterior lumbar tributaries of the LRV (p = 0.035).
 Conclusion: The venous system has a wide variety of variations, and the renal venous circulation is supported by number variations on the right in men and collaterals on the left in women.

Evaluation of left renal vein and IVC variations in MDCT examinations performed in patients with a preliminary diagnosis of renal calculi

Background/Aim: Left renal vein (LRV) and inferior vena cava (IVC) variations are not rare, an observation that is extremely important to understanding the presence of these structures before performing surgery. This study aimed to evaluate the type and frequency of IVC and LRV variations with multi-detector computer tomography (MDCT) in patients admitted with a preliminary diagnosis of renal calculi and to evaluate the relationship of these variations with renal calculi, renal cysts, and horseshoe kidneys. Methods: We retrospectively analyzed 1640 patients who underwent abdominal CT for suspicious renal calculi between January 2018 and December 2019. This retrospective cohort study consisted of 1604 patients after the exclusion criteria. Renal surgery and/or renal agenesis examinations without enough diagnostic quality due to motion artifacts were considered the exclusion criteria. Age, gender, presence and types of IVC and renal variations, and presence of renal calculi, renal cysts, and horseshoe kidney were recorded. The relationship between variation types and presence of renal calculi, renal cysts, and horseshoe kidneys was evaluated. Results: IVC and LRV variations were detected in 107 patients (6.7%). The prevalence of circumaortic LRV (CLRV) and retroaortic LRV (RLRV), left IVC, and double IVC in 65 patients was 4.1%, 2.4%, 0.1%, and 0.1%, respectively. Male gender predominance in both total and RLRV were found in the variations (P=0.033 and P=0.033, respectively). Urinary calculi were found in 1016 (63.3%) of the patients, kidney cysts in 247 (15.4%), and horseshoe kidneys in 10 (0.6%). No correlation between the presence of renal calculi, kidney cysts, and horseshoe kidney and the presence of variations in patients with LRV was found (P=0.433, P=0.215, and P=0.500, respectively). Conclusions: LRV and IVC variations are not uncommon. It is necessary to be informed about these variations before performing retroperitoneal surgery to prevent possible complications. LRV and IVC variations can be easily recognized in pre-diagnosed renal calculi on MDCT without the use of an intravenous contrast agent.

Agreement between subcostal and transhepatic longitudinal imaging of the inferior vena cava for the evaluation of fluid responsiveness: A systematic review.

Assessment of fluid-responsiveness is a key aspect of daily management in critically ill patients. Non-invasive evaluation of the variation of inferior vena cava (IVC) diameter during ventilation may provide useful information. However, a standard sagittal IVC visualization from the subcostal (SC) region is not always feasible. An alternative method to visualize the IVC is a coronal trans-hepatic (TH) approach. We performed a systematic search to explore the interchangeability of IVC evaluation with SC and TH views. We searched Medline and EMBASE to identify prospective studies. We did not consider the relationship between axial and sagittal visualization of the IVC. We included seven studies reporting data on IVC evaluation with both SC and TH IVC views. Four studies were conducted on spontaneously breathing patients/volunteers, two on fully mechanically ventilated patients, and one in a mixed population, with large heterogeneity regarding the analyses reported. Limits of agreement between SC and TH were large. Concordance of the IVC collapsibility/distensibility indices are not interchangeable between SC and TH view. Correlation between diameters measured with SC and TH approach and intra/inter-observer correlation produced variable results. An overview of the included studies suggests that longitudinal TH and SC assessment of IVC size and respiratory variation are not interchangeable. New studies with accurate data reporting and appropriate statistical analysis are needed to define proper cut-offs for fluid responsiveness when using TH approach for IVC visualization.

Correlation of Ultrasound-Based Hydration Assessment Measures with CVP and Clinical Hydration Status among Children Admitted to the PICU: A Prospective Observational Study

Abstract Purpose This article assesses the correlation of respiratory variation in inferior vena cava (IVC) with central venous pressure (CVP) in children. Secondary objective was to evaluate IVC variability with clinical hydration status. Methods IVC variability was assessed at the subcostal (SC) and right lateral (RL) region, and collapsibility index (CI) (spontaneously breathing) and distensibility index (DI) (positive pressure) and IVC/aortic ratio were calculated. Partial correlations were calculated between CI/DI with CVP adjusting for body mass index and age. Sensitivity of CI and DI to predict clinical dehydration was calculated using receiver operating characteristic curves. Results A total of 145 ultrasounds were performed on 72 patients (41% positive pressure). Only RL CI in spontaneously breathing patients strongly correlated with CVP (r = –0.65, p < 0.001). A moderate correlation was observed between CI and DI from SC and RL regions (r's = 0.38 and 0.47). Among spontaneously breathing patients, a significant difference was observed in the SC CI based on hydration status. For patients on positive pressure, IVC/aortic ratio had a significant difference. SC CI had the highest area under the curve (0.82) to detect dehydration with 80% sensitivity/87% specificity for a cutoff of 40%. Conclusion SC CI is the most reliable measure to assess the hydration status of spontaneously breathing children, while the IVC/aortic ratio performs well for patients under positive pressure. RL CI has strong negative correlation with CVP in spontaneously breathing patients.

Comparison of superior and inferior vena cava diameter variation measured with transthoracic echocardiography to predict fluid responsiveness in mechanically ventilated patients after abdominal surgery

BackgroundThe volume status of patients after major abdominal surgery constantly varies owing to postoperative diverse issues comprising fluid loss or capillary leakage secondary to systemic inflammatory reaction syndrome, et.al, the precise fluid responsiveness assessment is crucial for those patients. The purpose of this study is to validate the transthoracic ultrasonographic measurement of superior and inferior vena cava variation in predicting fluid responsiveness of mechanically ventilated patients after surgery.MethodsA total of 70 patients undergoing the scheduled major abdominal surgeries in the anesthesia ICU ward were included. The superior vena cava (SVC) collapsibility index (SVCCI), the inferior vena cava distensibility index (dIVC), SVC variation over the cardiac cycle (SVCV), and cardiac output (CO) were measured by transthoracic ultrasonography were recorded before and after fluid challenge test of 5 ml/kg crystalloid within 15 min. The responders were defined as a 15% or more increment in CO.ResultsThirty patients (42.9%) responded to fluid challenge, while the remnant forty patients (57.1%) did not. The areas under the ROC curve (AUC) of SVCCI, dIVC and SVCV were 0.885 (95% CI, 0.786–0.949; P < 0.0001) and 0.727 (95% CI, 0.608–0.827; P < 0.001) and 0.751 (95% CI, 0.633–0.847; P < 0.0001), respectively. AUCdIVC and AUCSVCV were significantly lower when compared with AUCSVCCI (P < 0.05). The optimal cutoff values were 19% for SVCCI, 14% for dIVC, and 15% for SVCV. The gray zone for SVCCI was 20%-25% and included 15.7% of patients, while 7%-27% for dIVC including 62.9% of patients and 9%-21% for SVCV including 50% of patients.ConclusionSuperior vena cava-related parameters measured by transthoracic ultrasound are reliable indices to predict fluid responsiveness. The accuracy of SVCCI in mechanically ventilated patients after abdominal surgery is better than that of dIVC and SVCV.Trial registrationChiCTR-INR-17013093. The initial registration date was 24/10/2017.

The diagnostic accuracy of inferior vena cava respiratory variation in predicting volume responsiveness in patients under different breathing status following abdominal surgery

BackgroundThe validation of inferior vena cava (IVC) respiratory variation for predicting volume responsiveness is still under debate, especially in spontaneously breathing patients. The present study aims to verify the effectiveness and accuracy of IVC variability for volume assessment in the patients after abdominal surgery under artificially or spontaneously breathing.MethodsA total of fifty-six patients after abdominal surgeries in the anesthesia intensive care unit ward were included. All patients received ultrasonographic examination before and after the fluid challenge of 5 ml/kg crystalloid within 15 min. The same measurements were performed when the patients were extubated. The IVC diameter, blood flow velocity–time integral of the left ventricular outflow tract, and cardiac output (CO) were recorded. Responders were defined as an increment in CO of 15% or more from baseline.ResultsThere were 33 (58.9%) mechanically ventilated patients and 22 (39.3%) spontaneously breathing patients responding to fluid resuscitation, respectively. The area under the curve was 0.80 (95% CI: 0.68–0.90) for the IVC dimeter variation (cIVC1) in mechanically ventilated patients, 0.87 (95% CI: 0.75–0.94) for the collapsibility of IVC (cIVC2), and 0.85 (95% CI: 0.73–0.93) for the minimum IVC diameter (IVCmin) in spontaneously breathing patients. The optimal cutoff value was 15.32% for cIVC1, 30.25% for cIVC2, and 1.14 cm for IVCmin. Furthermore, the gray zone for cIVC2 was 30.72 to 38.32% and included 23.2% of spontaneously breathing patients, while 17.01 to 25.93% for cIVC1 comprising 44.6% of mechanically ventilated patients. Multivariable logistic regression analysis indicated that cIVC was an independent predictor of volume assessment for patients after surgery irrespective of breathing modes.ConclusionIVC respiratory variation is validated in predicting patients' volume responsiveness after abdominal surgery irrespective of the respiratory modes. However, cIVC or IVCmin in spontaneously breathing patients was superior to cIVC in mechanically ventilated patients in terms of clinical utility, with few subjects in the gray zone for the volume responsiveness appraisal.Trial registrationChiCTR-INR-17013093. Initial registration date was 24/10/2017.

Double inferior vena cava with bilateral mild hydronephrosis: a rare case report

A 47-year-old female with a history of antiphospholipid syndrome and ischemic stroke was presented to the emergency department due to abdominal pain and bloody vomiting. Ultrasonography showed double inferior vena cava and bilateral mild hydronephrosis. Furthermore, the abdominal computed tomography (CT) scan did not show any evidence of urolithiasis. The ultrasound images of distinctive developmental variations of inferior vena cava and other veins are important to be known. Vascular anomalies, although rare, should be taken into account in the differential diagnosis of focal lesions within the abdominal cavity. Double IVC might have been the cause of hydronephrosis in our patient.

Comparison of volume assessment methods in transurethral resection of the prostate

To compare the value of inferior vena cava (IVC) variation, thoracic fluid content (TFC), and central venous pressure (CVP) in transurethral resection of the prostate (TURP) for systemic volumetric load. Eighty male patients who had undergone TURP at our hospital from July to August 2021 were enrolled. Before and after anesthesia induction, IVC variation and TFC were recorded every 15 min and then 15 min after surgery. The ability of IVC variation, TFC, and CVP to predict fluid responsiveness was assessed using receiver operator characteristic (ROC) curves. The Pearson correlation test was used to analyze the correlations among intraoperative IVC variation, TFC, CVP and the stroke volume index (SVI). ROC curve evaluation: the area under the ROC curve (AUC) of IVC variation was 0.82 (p &lt; 0.01), while that of CVP and TFC was 0.61 (p = 0.16) and 0.45 (p = 0.28), respectively. Since the operation began, ∆IVC variation showed a significant negative correlation with ∆SVI at different time points. ∆CVP and ∆TFC showed a poor correlation with ∆SVI. IVC variation was superior to TFC and CVP to predict fluid responsiveness and assess the volume status and volume responsiveness of patients undergoing TURP.

Efficacy analysis of inferior vena cava variability combined with difference of central venous-to-arterial partial pressure of carbon dioxide on guiding fluid resuscitation in patients with septic shock

To investigate the effect of inferior vena cava variability (IVCV) combined with difference of central venous-to-arterial partial pressure of carbon dioxide (Pcv-aCO2) on guiding fluid resuscitation in septic shock. Patients with septic shock admitted to the department of critical care medicine of Jiangxi Provincial People's Hospital from January 1, 2018 to December 31, 2020 were enrolled, and they were divided into control group and observation group according to random number table method. Patients in both groups were given fluid resuscitation according to septic shock fluid resuscitation guidelines. The patients in the control group received fluid resuscitation strictly according to the early goal-directed therapy (EGDT) strategy. Resuscitation target: central venous pressure (CVP) 12-15 cmH2O (1 cmH2O≈0.098 kPa), mean arterial pressure (MAP) > 65 mmHg (1 mmHg≈0.133 kPa), mean urine volume (UO) > 0.5 mL×kg-1×h-1, central venous oxygen saturation (ScvO2) > 0.70. In the observation group, the endpoint of resuscitation was evaluated by IVCV dynamically monitored by bedside ultrasound and Pcv-aCO2. Resuscitation target: fixed filling of inferior vena cava with diameter > 2 cm, IVCV < 18%, and Pcv-aCO2 < 6 mmHg. The changes in recovery indexes before and 6 hours and 24 hours of resuscitation of the two groups were recorded, and the 6-hour efficiency of fluid resuscitation, 6-hour lactate clearance rate (LCR) and 6-hour and 24-hour total volume of resuscitation were also recorded; at the same time, the duration of mechanical ventilation, length of intensive care unit (ICU) stay, 28-day mortality and the incidence of acute renal failure and acute pulmonary edema between the two groups were compared. A total of 80 patients were enrolled in the analysis, with 40 in the control group and 40 in the observation group. The MAP, CVP and ScvO2 at 6 hours and 24 hours of resuscitation in the two groups were significantly higher than those before resuscitation, while Pcv-aCO2 and blood lactic acid (Lac) were significantly decreased, and UO was increased gradually with the extension of resuscitation time, indicating that both resuscitation endpoint evaluation schemes could alleviate the shock state of patients. Compared with before resuscitation, IVCV at 6 hours and 24 hours of resuscitation in the observation group were decreased significantly [(17.54±4.52)%, (18.32±3.64)% vs. (27.49±10.56)%, both P < 0.05]. Compared with the control group, MAP and ScvO2 at 6 hours of resuscitation in the observation group were significantly increased [MAP (mmHg): 69.09±4.64 vs. 66.37±4.32, ScvO2: 0.666±0.033 vs. 0.645±0.035, both P < 0.05], 24-hour MAP was increased significantly (mmHg: 75.16±3.28 vs. 70.12±2.18, P < 0.05), but CVP was relatively lowered (cmH2O: 9.25±1.49 vs. 10.25±1.05, P < 0.05), indicating that the fluid resuscitation efficiency was higher in the observation group. Compared with the control group, 6-hour LCR in the observation group was significantly increased [(55.64±6.23)% vs. (52.45±4.52)%, P < 0.05], 6-hour and 24-hour total volume of resuscitation was significantly decreased (mL: 2 860.73±658.32 vs. 3 568.54±856.43, 4 768.65±1 085.65 vs. 5 385.34±1 354.83, both P < 0.05), the duration of mechanical ventilation was significantly shortened (days: 6.78±3.45 vs. 8.45±2.85, P < 0.05), while the incidence of acute pulmonary edema was significantly decreased [2.5% (1/40) vs. 20.0% (8/40), P < 0.05]. There was no significant difference in the length of ICU stay, 28-day mortality or incidence of acute renal failure between the two groups. Dynamic monitoring of IVCV and Pcv-aCO2 can effectively guide the early fluid resuscitation of patients with septic shock, and compared with EGDT, it can significantly shorten the duration of mechanical ventilation, reduce the amount of fluid resuscitation, and reduce the incidence of acute pulmonary edema. Combined with its non-invasive characteristics, it has certain clinical advantages.

Does respiratory variation in inferior vena cava diameter predict fluid responsiveness in adult patients? A systematic review and meta-analysis of diagnostic accuracy studies

Objectives: To systematically review the diagnostic utility of the respiratory variation of the inferior vena cava diameter measured using ultrasonography for predicting fluid responsiveness in adult patients and compare the three commonly used equations, inferior vena cava distensibility, inferior vena cava collapsibility and inferior vena cava variability. Methods: We searched PubMed, Scopus, Web of Science and Cochrane library, and included studies investigating the diagnostic accuracy of the respiratory variation of the inferior vena cava measured using ultrasonography compared to a reference standard for measuring cardiac output after a fluid challenge for fluid responsiveness, and stratified participants as fluid responsive or not. We included studies conducted in the emergency department or intensive care unit. We excluded studies on paediatric, prehospital, cancer, pregnant, dialysis patients or healthy volunteers. Results: We retrieved 270 records and excluded 171 because of irrelevance, patient population or publication type. We screened the abstracts of 99 studies and then the full texts of 42 studies. Overall, 21 studies with 1321 patients were included, of whom 689 (52%) were fluid responsive. The mean threshold value for positive inferior vena cava distensibility, inferior vena cava collapsibility and inferior vena cava variability was 17%, 35% and 12%, respectively. The heterogeneity between studies was high. Bivariate diagnostic random-effects meta-analysis was used to calculate the summary receiver operating characteristics curves. The overall accuracy, sensitivity and specificity of respiratory variation of the inferior vena cava diameter were 0.85, 0.72 and 0.81, respectively. The accuracy of inferior vena cava distensibility and inferior vena cava collapsibility was similar. The diagnostic utility of respiratory variation of the inferior vena cava diameter was lower but not statistically significant in mechanically ventilated patients compared with spontaneous breathing for predicting fluid responsiveness. Conclusion: The respiratory variation of the inferior vena cava diameter has moderate diagnostic utility for predicting fluid responsiveness independent of the equation used.

Comparison of Respiratory Variations of Subclavian Vein and Inferior Vena Cava in Hospitalized Patients with Kidney Disease.

BackgroundAccurate assessment of relative intravascular volume is critical for appropriate volume management of patients with kidney disease. Respiratory variations of inferior vena cava (IVC) diameter have been used and may correlate with those of subclavian vein (SCV) by bedside ultrasound. The purpose of this study was to assess the relationship between SCV and IVC respiratory variations by bedside ultrasound in a large group of hospitalized patients with acute and/or chronic kidney disease.MethodsWe compared 160 paired SCV and IVC bedside ultrasound studies from 102 semi-recumbent hospitalized adult patients with kidney disease. Patient encounters in which the SCV or IVC could not be clearly visualized were excluded. Collapsibility index=(Dmax–Dmin)/Dmax*100%; D=venous diameter.ResultsRelationships between SCV collapsibility index and IVC collapsibility index were not different for longitudinal and transverse views of the SCV. Correlation of SCV collapsibility index with IVC collapsibility index was 0.75 for mechanical ventilation (n=65, P<0.0001) and 0.67 for spontaneous breathing (n=95, P<0.0001). IVC collapsibility index cut-offs <20% for hypervolemia and >50% for hypovolemia corresponded to SCV collapsibility index cut-offs of <22% and >39%, respectively, for both mechanical ventilation and spontaneous breathing encounters. Using these cut-offs for SCV collapsibilities, assessment as hypervolemia versus not-hypervolemia had maximal sensitivity and specificity for predicting respective IVC collapsibility cut-offs of 88% for mechanical ventilation and 74% for spontaneous breathing, and assessment as hypovolemia versus not-hypovolemia had maximal sensitivity and specificity of 91% and 70%, respectively. Concordance, defined as agreement between assessment using SCV CI and assessment using IVC CI, was 85% for mechanical ventilation and 72% for spontaneous breathing when differentiating hypervolemia versus not-hypervolemia and was 89% and 71% respectively when differentiating hypovolemia versus not-hypovolemia.ConclusionAssessment using SCV collapsibility index in the semi-recumbent position has a reasonable concordance with assessment using IVC collapsibility index for both spontaneous breathing and mechanical ventilation, in a wide range of hospitalized patients with concurrent kidney disease, and may be a useful adjunct to assess relative intravascular volume in patients with kidney disease.

COMPARISON OF NONINVASIVE HEMODYNAMIC MONITORS, RESPIRATORY VARIATION IN INFERIOR VENA CAVA, AND STROKE VOLUME VARIANCE MEASURED BY ESTIMATION OF FINGER CUFF TECHNOLOGY FOR PREDICTION OF FLUID RESPONSIVENESS IN SEPTIC SHOCK

SESSION TITLE: Education, Research, and Quality Improvement Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: ClearSight finger cuff technology is a new addition to non-invasive hemodynamic monitoring and uses infrared photo-plethysmography to measure finger artery diameter to estimate brachial artery pressure to determine cardiac output (CO), cardiac index (CI) and stroke volume variance (SVV). We hypothesized that SVV measurement from finger cuff technology is comparable to invasive arterial hemodynamic monitoring and the delta change in inferior vena cava (IVC) size with respiration on ultrasound in predicting fluid responsiveness in septic shock. METHODS: This was an observational prospective pilot study in a residency program. Patients in the ICU requiring vasopressors for septic shock within 24 hours of admission were monitored hemodynamically with both FloTrac through an arterial catheter and a ClearSight finger cuff. A baseline change of IVC size with respiration was measured with ultrasound. If no contraindication, a passive leg raise was performed followed by a 500ml crystalloid challenge. The CO, CI, SVV were compared between both devices as well as repeat measurement of the delta IVC to evaluate fluid responsiveness. Criteria for fluid responsiveness was a ≥25% delta IVC variation with respiration or ≥12% SVV on hemodynamic monitoring. RESULTS: Fluid responsiveness was predicted in 9 of the 13 patients included in this study based on the delta IVC. 2 of 13 patients in the FloTrac group and 1 patient in the ClearSight group were predicted to be fluid responsive based on SVV. After being fluid challenged, the 5 patients initially predicted to be fluid responsive had a decrease in the delta IVC variation. In all 13 patients, there was an overall decrease in the SVV percentage even if they were not initially predicted to be fluid responsive. Additionally, there was also a correlation in the CO, CI, and SVV measurements between the FloTrac and ClearSight devices. CONCLUSIONS: There were several limitations in this study which include small sample size, operator dependence in measurements in delta IVC, enrollment in later stage in ICU rather than in the ED after receiving a 30ml/kg crystalloid bolus, and questionable accuracy in patients requiring multiple and high doses of vasopressors. However, we found that hemodynamic measurements through an invasive arterial catheter with FloTrac and noninvasive measurement with ClearSight finger cuff were comparable. CLINICAL IMPLICATIONS: The use of non-invasive hemodynamic monitoring via finger cuff technology may be helpful when evaluating fluid responsiveness in septic shock patients. DISCLOSURES: No relevant relationships by Saiyed Ali, source=Web Response No relevant relationships by Kristine Galang, source=Web Response No relevant relationships by Gurinder Singh, source=Web Response

Embryological and surgical considerations of absent infra-renal part of inferior venacava and left renal vein

Background: Development of inferior vena cava (IVC) is a complex process that involves the anastomoses between three pairs of embryonic veins. Specific permutations exist in the venous plane of the abdomen and pelvis resulting in variations such as single left IVC, double IVC, and left renal retroaortic vein. Anomalies of the inferior vena cava and renal veins occur infrequently but may contribute to serious morbidity throughout surgical exploration if unidentified. Most anomalies remain asymptomatic until surgical intervention or clinical presentation with thromboembolic complications.&#x0D; Aims and Objective: Our research is aimed to link embryology with developmental disorder and the complications associated with the anomalous vessels in the field of surgery.&#x0D; Materials and Methods: Ten IUD fetuses (ranging from 20 weeks to term fetuses) were collected from the O&amp;G department of the college and injected locally with dilute formalin and placed in containers filled with formalin. Dissection of the fetuses was done to identify congenital anomalies.&#x0D; Results: The external appearance of the 28-week-old fetus showed no gross anomaly. Examination abdominal cavity showed absent infrarenal segment of IVC and left renal vein. The right renal vein was seen running a long course to the left side with tributaries of lumbar veins and was seen continuing as the left femoral vein medial to the femoral artery. Segments of suprarenal and renal IVC were present.&#x0D; Conclusion: Correlating anomalies and variations of IVC and its tributaries to embryology. However, understanding of such anomaly is necessary to avoid significant diagnostic pitfalls and in preoperative surgicaland radiological intervention planning.

Duplication of the inferior vena cava: evidence of a novel type IV.

Anatomical variations of the inferior vena cava, including the double inferior vena cava or isolated left inferior vena cava, are uncommon and of great clinical importance. Inferior vena cava variations signify predisposition to deep vein thrombosis and may complicate retroperitoneal surgeries including abdominal aortic surgery. Failure to recognize such variations may predispose a patient to life- threatening complications. This prospective anatomical study assessed 129 cadavers for variations of the inferior vena cava. One of the 129 cadavers (0.78%) possessed a double inferior vena cava and none (0%) possessed an isolated left inferior vena cava. The left-sided inferior vena cava was of a larger diameter than that of the right-sided inferior vena cava - opposite of what would be seen in a Type III duplication. Therefore, this observation expands the three-type classification system to include a Type IV duplication.

Significance of Early Postoperative Arterial Lactic Acid, Inferior Vena Cava Variability, and Central Venous Pressure in Hypovolemic Shock.

Introduction Up to one-third of patients admitted to the ICU are in circulatory shock, and early recognition of the condition is vital if subsequent tissue injuries are to be avoided. We would like to know what role the arterial lactic acid, inferior vena cava variability, and CVP (central venous pressure) play in the early stages of shock. Methods This is a retrospective study of patients who underwent surgical resuscitation in the Department of Critical Care Medicine. We use the ROC (receiver-operating characteristic) curve to evaluate the significance of each indicator in the diagnosis. For correlation analysis between groups, we first use linear regression for processing and then analysis with correlation. Results The ROC curve analysis shows that the area under the curve of the lactic acid group was 0.9272, the area under the curve of the inferior vena cava variability group was 0.8652, and the area under the curve of the CVP group was 0.633. Correlation analysis shows that the inferior vena cava variability and arterial lactic acid Pearson's r = 0.2863 and CVP and arterial lactic acid Pearson's r = 0.0729. Conclusion The diagnostic value of arterial lactate is still very high and can still be used as an early warning indicator to help clinicians be alert to the microcirculatory disorders that have emerged quietly. The degree of inferior vena cava variability is linearly related to arterial lactic acid and can also be used as a reference indicator for early evaluation of shock. The diagnostic value of CVP is obviously lower.

Respiratory variations of inferior vena cava fail to predict fluid responsiveness in mechanically ventilated patients with isolated left ventricular dysfunction

BackgroundRespiratory variation of inferior vena cava is problematic in predicting fluid responsiveness in patients with right ventricular dysfunction. However, its effectiveness in patients with isolated left ventricular systolic dysfunction (ILVD) has not been reported. We aimed to explore whether inferior vena cava diameter distensibility index (dIVC) can predict fluid responsiveness in mechanically ventilated ILVD patients.MethodsPatients admitted to the intensive care unit who were on controlled mechanical ventilation and in need of a fluid responsiveness assessment were screened for enrolment. Several echocardiographic parameters, including dIVC, tricuspid annular plane systolic excursion (TAPSE), left ventricular ejection fraction (LVEF), and LV outflow tract velocity–time integral (VTI) before and after passive leg raising (PLR) were collected. Patients with LV systolic dysfunction only (TAPSE ≥ 16 mm, LVEF < 50%) were considered to have isolated left ventricular systolic dysfunction (ILVD).ResultsOne hundred and twenty-nine subjects were enrolled in this study, among them, 28 were labelled ILVD patients, and the remaining 101 were patients with normal LV function (NLVF). The value of dIVC in ILVD patients was as high as that in NLVF patients, (20% vs. 16%, p = 0.211). The ILVD group contained a much lower proportion of PLR responders than NLVF patients did (17.9% vs. 53.2%, p < 0.001). No correlation was detected between dIVC and ΔVTI in ILVD patients (r = 0.196, p = 0.309). dIVC was correlated with ΔVTI in NLVF patients (r = 0.722, p < 0.001), and the correlation was strengthened compared with that derived from all patients (p = 0.020). A receiver-operating characteristic (ROC) analysis showed that the area-under-the-curve (AUC) of dIVC for determining fluid responsiveness from ILVD patients was not statistically significant (p = 0.251). In NLVF patients, ROC analysis revealed an AUC of 0.918 (95% CI 0.858–0.978; p < 0.001), which was higher than the AUC derived from all patients (p = 0.033). Patients with LVEF below 40% had a lower ΔVTI and fewer PLR responders than those with LVEF 40–50% and LVEF above 50% (p < 0.001).ConclusiondIVC should be used with caution when critically ill patients on controlled mechanical ventilation display normal right ventricular function in combination with abnormal left ventricular systolic function.

Anatomy and Physiology for the Abdominal Aortic Aneurysm Repair.

In 2006, commercially produced endovascular aneurysm repair (EVAR) devices were approved by the Japanese Ministry of Health, Labour and Welfare, and their cost began to be covered by Japanese medical insurance. Meanwhile, the number of juxtarenal abdominal aortic aneurysms (AAA) to need the suprarenal clamp are increasing and the number of infra-renal AAAs are decreasing for open repair. In this era when EVAR has been growing rapidly for 11 years, it is a good opportunity to learn the surgical repair of AAA. I review the basic and advanced anatomy and physiology concepts which are needed for abdominal aortic repair, which are the proximal site (exposure of the proximal site, variation of renal arteries, variation of inferior vena cava and left renal vein, arcade of visceral branches of abdominal aorta, and coeliac plexus) and distal site (iliac artery, superior hypogastric plexus, ureter, inferior mesenteric artery, and lumbar arteries) separately. (This is a translation of Jpn J Vasc Surg 2019; 28: 173–177.)