Measurement site of inferior vena cava diameter affects the accuracy with which fluid responsiveness can be predicted in spontaneously breathing patients: a post hoc analysis of two prospective cohorts

Abstract

Background The collapsibility index of the inferior vena cava (cIVC) has potential for predicting fluid responsiveness in spontaneously breathing patients, but a standardized approach for measuring the inferior vena cava diameter has yet to be established. The aim was to test the accuracy of different measurement sites of inferior vena cava diameter to predict fluid responsiveness in spontaneously breathing patients with sepsis-related circulatory failure and examine the influence of a standardized breathing manoeuvre. Results Among the 81 patients included in the study, the median Simplified Acute Physiologic Score II was 34 (24; 42). Sepsis was of pulmonary origin in 49 patients (60%). Median volume expansion during the 24 h prior to study inclusion was 1000 mL (0; 2000). Patients were not severely ill: none were intubated, only 20% were on vasopressors, and all were apparently able to perform a standardized breathing exercise. Forty-one (51%) patients were responders to volume expansion (i.e. a ≥ 10% stroke volume index increase). The cIVC was calculated during non-standardized (cIVC-ns) and standardized breathing (cIVC-st) conditions. The accuracy with which both cIVC-ns and cIVC-st predicted fluid responsiveness differed significantly by measurement site (interaction p < 0.001 and < 0.0001, respectively). Measuring inferior vena cava diameters 4 cm caudal to the right atrium predicted fluid responsiveness with the best accuracy. At this site, a standardized breathing manoeuvre also significantly improved predictive power: areas under ROC curves [mean and (95% CI)] for cIVC-ns = 0.85 [0.78–0.94] versus cIVC-st = 0.98 [0.97–1.0], p < 0.001. When cIVC-ns is superior or equal to 33%, fluid responsiveness is predicted with a sensitivity of 66% and a specificity of 92%. When cIVC-st is superior or equal to 44%, fluid responsiveness is predicted with a sensitivity of 93% and a specificity of 98%. Conclusion The accuracy with which cIVC measurements predict fluid responsiveness in spontaneously breathing patients depends on both the measurement site of inferior vena cava diameters and the breathing regime. Measuring inferior vena cava diameters during a standardized inhalation manoeuvre at 4 cm caudal to the right atrium seems to be the method by which to obtain cIVC measurements best-able to predict patients’ response to volume expansion.

Diagnostic Accuracy of Ultrasonographic Respiratory Variation in the Inferior Vena Cava, Subclavian Vein, Internal Jugular Vein, and Femoral Vein Diameter to Predict Fluid Responsiveness: A Systematic Review and Meta-Analysis

“…After the full-text review, 62 articles were excluded due to insufficient data ( n = 36), lack of 2-by-2 data ( n = 25), and not being original ( n = 1). Finally, 30 studies [ 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 ] comprising 1719 patients were included in this review ( Figure 1 ); detailed information about the eligible studies is shown in Table 1 . In cases of the IJV [ 29 , 36 , 42 ], FV (was not detected), and SCV [ 41 ], we were not able to conduct the meta-analysis due to an insufficient number of studies.…”

“…Thus, we extracted the subset of 9 mL/kg TV. Three studies [ 39 , 40 , 48 ] reported on subsets of patients with standardized breathing and spontaneous breathing. We extracted subsets of spontaneous breathing because other studies included only patients with spontaneous breathing.…”

“…We extracted the result of the training dataset by humans because the number of test datasets was much smaller than the test set (20 vs. 175). Caplan et al [ 48 ] reported different results according to the measuring site (1, 2, 3, and 5 cm apart from the aortocaval junction). We extracted a subset of 3 cm from the aortocaval junction because it was similar to other eligible studies.…”

“…All 30 eligible studies were summarized in Table 1 . Twenty-eight studies [ 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 ] comprised the measurement of the IVC. Only three studies [ 29 , 36 , 42 ] comprised that of the IJV and one study [ 41 ] comprised that of the SCV.…”

Rule of RUSH protocol in management of shocked patients

“…Yanagawa and colleagues (17) found that there is an increase in IVC e diameter after resuscitation from 7.7 to 13.5 mm, (P=0.001). Caplan et al (18) demonastrate that the measurement of cIVC is a fast, non-invasive and easy-to-implement tool which could improve clinical management of the acute phase of sepsis in SB patient & interaction between cIVC and FR is dependent on the way in which IVC diameter is measured: the best diagnostic accuracy for predicting FR is at 4 cm caudal to the cavo-atrial junction Our study found that there was a positive significant correlation between sonographic measurements of IVC diameter (expiratory and inspiratory) and CVP. This result agreed with 13) also found a significant correlation between the CVP and IVC-CI.…”