Noninvasive estimation of intravascular volume status in cirrhosis by dynamic size and collapsibility indices of the inferior vena cava using bedside echocardiography

Abstract

Background and Aim Echocardiographic assessment of the inferior vena cava diameter (IVCD) and collapsibility index (IVCCI) is a noninvasive estimate of intravascular volume status (IVS) but requires validation for cirrhosis. We evaluated IVC dynamics in cirrhosis and correlated it with conventional tools such as central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), and right atrial pressure (RAP). Methods A total of 673 consecutive cirrhotic patients were screened by echocardiography, and 125 patients underwent right heart catheterization with recording of hepatic venous pressure gradient (HVPG), RAP, pulmonary artery (PA) pressure, and PCWP. CVP data were available for 80 (64%) patients, and finally, 76 patients (84% male, 50% ethanol related, mean age 52.1 years, 57.8% with ascites) with complete data were enrolled. Results The mean CVP measured was 12.8 ± 4.8 mmHg, and IVCCI was 29.5 ± 10.9%. The IVCD ranged from 0.97 to 2.26 cm and from 0.76 to 1.84 cm during expiration and inspiration, respectively, with a mean of 1.8 ± 0.9 cm. The mean IVCD correlated with RAP ( r = 0.633, P = 0.043) but not with HVPG ( r = 0.344, P = 0.755), PCWP ( r = 0.562, P = 0.072), or PA pressure ( r = 0.563, P = 0.588). A negative linear correlation was observed between the CVP and the IVCCI ( r = −0.827, P = 0.023) in all patients and substratified for those with ( r = −0.748, P = 0.039) and without ascites ( r = −0.761, P = 0.047). A positive correlation was observed between CVP and IVCD max ( r = 0.671, P = 0.037) and IVCD min ( r = 0.612, P = 0.040). Conclusions IVCD and collapsibility index provides noninvasive IVS assessment, independent of HVPG or ascites, with the potential for calculating fluid requirements in cirrhosis.

Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era

“…1 POC TTE is a simple, iterative and cost-effective tool in evaluation of cardiac conditions like myocardial infarction, pulmonary embolism, shock states (hypovolemic or vasoplegic), systolic and diastolic dysfunction in patients with cirrhosis and acute-on-chronic liver failure (ACLF), and helps determine treatment pathways like thrombolysis, volume resuscitation and vasopressors. 2,3 In the liver specific conditions, POC TTE helps in clinical management in patients with undifferentiated dyspnea, sepsis and shock, ACLF with organ failures, variceal bleeding, perioperative assessment during surgery and liver transplantation. In case of critically ill patients with liver disease who present with shock, a screening evaluation is performed by the primary physician to determine the specific flow dynamics of the hypotensive state, but an expert cardiology evaluation is essential to manage a cardiac condition contributing to multifactorial shock.…”

“…Since there is marked peripheral vasodilation in cirrhosis, the latent myocardial and cardiac abnormalities are often undiagnosed and manifest as heart failure in response to an additional insult like sepsis or surgery. 3,12,13 Early diagnosis of pulmonary embolism and myocardial infarction (MI) at the bedside is essential in the Liver ICU, as movement for tests like computed tomography is not always feasible and electrocardiography is not diagnostic. Expert consultations and management of ST elevation MI, percutaneous coronary intervention (PCI), reperfusion strategy is often delayed in the COVID-19 era with an increase in hospital mortality.…”

“…We have previously shown that the IVC diameter and collapsibility index (IVCCI) IVC max -IVC min IVC max × 100 is the most reliable iterative marker for estimation of volume status of spontaneously breathing patients with cirrhosis. 3 However, estimation of dynamic indices is affected in patients on mechanical ventilation especially those on high positive end expiratory pressure. Muller et al and Airapetian et al showed that increase in cardiac output with fluid bolus can be expected if the IVCCI is >40% and >42% respectively.…”

Can Inferior Vena Cava Diameter and Collapsibility Index Be a Predictor in Detecting Preoperative Intravascular Volume Change in Pediatric Patients?

“…Therefore, the sonographic measurement of IVC is an effective and noninvasive method that can be used to estimate CVP. [8][9][10] Many studies have been conducted to determine the fluid deficit with the help of the IVC diameter and collapsibility index (CI) in the postpartum period, in trauma, cardiogenic-hypovolemic and septic shock patients. [11][12][13] However, to our knowledge, there is no study evaluating preoperative intravascular volume with IVC diameter and CI in the pediatric patient group.…”

Respiratory variation of inferior vena cava diameter and central venous pressure in ventilated and non-ventilated children in fluid refractory septic shock: an observational study

“…3 However, most of the studies have been done in the adult patients. [4][5][6] So, this observational study was designed to study the Respiratory Variation in the IVC Diameter (RV-IVCD) in septic shock patients of the paediatric age group, and their correlation with the CVP, in both spontaneously breathing and in patients on invasive mechanical ventilation.…”