Ultrasonographic inferior vena cava diameter response to trauma resuscitation after 1 hour predicts 24-hour fluid requirement

Abstract

Introduction: Identification of occult hypovolemia in trauma patients at admission can be difficult without additional laboratory evaluation or advanced imaging. We hypothesized that in acute trauma patients, the response of ultrasound-measured minimum inferior vena cava diameter (IVCD MIN ), IVC Collapsibility Index (IVCCI) or minimum internal jugular diameter (IJVD MIN ) or IJV Collapsibility Index (IJVCI) in repeated ultrasound examinations (USA-IVC) during up to 1 hour of standard-of-care intravenous fluid resuscitation would predict 24hour resuscitation intravenous fluid requirements (24FR). Methods: An NTI funded, AAST-MITC group prospective, multi-institutional cohort trial was conducted at 4 Level I Trauma Centers. Major trauma patients were screened in the supine position for an IVCD of 12 mm or IVCCI of 50% or less on the initial FAST examination for enrollment. A second IVCD was obtained 40-60 minutes later, after the patient received standard-of-care fluid resuscitation. Patients whose second measurement IVCD was less than 10mm were deemed Non-Responders (NON-RESP), those at or greater than 10mm were Responders (RESP). Prehospital fluid, initial resuscitation fluid and 24FR were recorded. Demographics, ISS, arterial blood gasses, ICU admission, length-of-stay, interventions and complications were recorded. Means were compared by ANOVA and categorical variables were compared via Chi-square. Receiver-operator characteristic (ROC) curves and gray area analysis were used to compare the IVC and IJV measures and to Base Excess (BE), ISS and other 24FR predictors.Results: There were 4798 patients screened by FAST-IVC, 196 were identified with admission IVCD of 12 mm or IVCCI of 50% or less, 144 were enrolled and had useable Abstract imagery. After 1 hour of standard of care resuscitation, there were 86 RESP and 58 NON-RESP. There were no significant differences between groups in demographics. initial hemodynamics or laboratory measures. NON-RESP had smaller IVCD (6.0mm ± 3.7 vs.14.2mm ± 4.3, p< 0.001) and higher IVCCI 41.7% ± 30.0 vs. 13.2% ± 12.7, p< 0.001) but no significant difference in IJVD or IJVCCI. RESP had significantly greater 24FR than NON-RESP (2503ml ± 1751 vs. 1243ml ± 1130 0.003). ROC analysis indicates IVCD MIN predicted 24FR (AUC= 0.74, C.I.: 0.64-0.84, p<0.001) as did IVCCI (AUC= 0.75, C.I.: 0.65-0.85, p<0.001) not IJVD (AUC= 0.48, C.I.: 0.24-0.60, p=N.S.) or IVCCI (AUC= 0.54, C.I.: 0.42-0.67, p=N.S.) and more predictive than ISS (AUC=0.65, C.I.:0.54-0.76, p=0.007) in predicting 24FR. Conclusion: Ultrasound assessed IVCD MIN and IVCCI but not IJ diameter response to initial major trauma patient resuscitation predicts 24-hour fluid resuscitation requirements.

Accuracy of preoperative evaluation of inferior vena cava collapsibility index and caval aorta index for prediction of hypotension after induction of general anesthesia: a prospective observational study

“…There may be other causative factors of hypotension as well, including the variability of the studied population comprising of adults, young adults, geriatrics, pregnant, traumatic and septic patients. [24][25][26][27][28] In concordance with our results, some other researchers found that preoperative evaluation of IVC parameters including IVCCI are not good predictors. Considering the possibility of hypotension following SA neither dIVCmax nor IVCCI values obtained prior to SA serve as reliable predictors of post-spinal hypotension, there was no statistical variation among the cases considering hypotension following SA correlated with dIVCmax and IVCCI.…”

“…Doucet et al27 examined the ability of US IVCDmin and IVCCI to identify occult hypovolemia in trauma patients, and found that these parameters offer a quick and noninvasive method of determining the 24-h fluid resuscitation of severe trauma patients within a single hour of admission.…”

Point-of-Care Ultrasound for the Trauma Anesthesiologist

“…Very few studies have focused on the use of POCUS as an indication of volume status specifically in trauma patients. Doucet et al [ 11 ••] showed that ultrasound measurements of the IVC during the first hour of resuscitation can predict the amount of fluid resuscitation necessary for the first 24 h in major trauma patients [ 11 ••].…”

Ultrasound Assessment of the Inferior Vena Cava for Fluid Responsiveness: Making the Case for Skepticism

“…Of these, six [21][22][23][24][25][26] are best described as negative endeavors (note 2), with 5 others positive. [27][28][29][30][31] The 5 positive papers form an interesting hypothesis which should motivate the undertaking of larger confirmatory studies, but the preponderance of small-study evidence does not clearly support the widespread use of this tool.…”