Justin Bowra: IVC Filling: The Ultimate Myth

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Bowra examines the possibility of 'turning off the machine' and behaving like a doctor versus a detailed examination of the IVC.

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  • If the studies measured a comprehensive and specific variety of locations and view and had a large population, that would be nice, considering the first papers on this subject are more than 30 years old. It seems though that comparison invasive measurement population is limiting along with no major profit motive capital investment in studies.
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  • 2 probes/machines in cross formation could keep the measuments centered.
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  • the best of the best on this myth
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  • Let’s look at IVCD first.
  • Just looked at IVCD, not IVCCI Dipti A et al. Role of inferior vena cava diameter in assessment of volume status: a meta-analysis. AJEM 2012 (30). 1414 -19.
  • Akilli / Weekes [24 Ps]: IVC 14-15mm in shocked patients 3 others [Sefidbakht/ Yangawax2]: 14-15mm in normals
  • Weekes, patients’ IVCDs went from 10-20mm [shocked] up to 16-24mm [clinically improved after IVT]
  • C onfounder: IVCD increases proportionally with the positive end expiratory pressure
  • R ight heart disease, chronic lung disease, high intrathoracic pressures of any cause…
  • (Blehar et al, 2009: 46 patients) BUT low IVCCI & SOB also occurs in: primary pulm HT, massive PE, PTX …
  • R eference: Kircher et al 1990: 83 patients. Nagdev 2010: 73 patients, some ventilated G old standard = catheter measurement of RA pressure performed within 24h. = One study, with a lousy gold standard.
  • (Nagdev 2010: 73 patients, some ventilated) Weekes’ IVCCI went from16-72% (median 45%) to 7-33% (22%) Y et Sefidbakht found that shocked trauma patients ’ IVCCI was only 27%, and normotensive patients 20%. U sing Nagdev ’ s study, you ’ d predict that even the shocked patients would have a high CVP … SO WHAT ’ S GOING ON?
  • R ight heart disease, chronic lung disease, high intrathoracic pressures of any cause…
  • (Nagdev 2010: 73 patients, some ventilated) Y et Sefidbakht found that shocked trauma patients ’ IVCCI was only 27%, and normotensive patients 20%. U sing Nagdev ’ s study, you ’ d predict that even the shocked patients would have a high CVP … SO WHAT ’ S GOING ON?
  • M aybe CVP itself doesn ’ t correlate well with fluid status. A nd maybe ‘ fluid status ’ is the wrong question. So let’s try a different question: does IVC ultrasound correlate with fluid responsiveness?
  • Lanspa M et al. APPLYING DYNAMIC PARAMETERS TO PREDICT HEMODYNAMIC RESPONSE TO VOLUME EXPANSION IN SPONTANEOUSLY BREATHING PATIENTS WITH SEPTIC SHOCK. Shock 2013. 39(2). pp. 155-160
  • Muller L et al. Respiratory variations of inferior vena cava diameter to predict fluid responsiveness in spontaneously breathing patients with acute circulatory failure: need for a cautious use. Critical Care 2012, 16:R188
  • KIMURA: mean IVCCI=0.8 versus 0.57
  • SMALL STUDY, (94 patients)
  • Perera et al [RUSH exam] recommends in addition: Akilli measured here instead.
  • Blehar 2012. IVC craniocaudal movt = 2.2cm Even mediolat movement of 4mm!
  • And Blehar
  • Blehar 4mm mediolateral movement.
  • (Does the diaphragm hold open the IVC?) (Is the IVC more sensitive to intra-abdominal pressure and probe pressure as you go down the diaphragm?)
  • Add Moretti …. & also Muller L et al. Respiratory variations of inferior vena cava diameter to predict fluid responsiveness in spontaneously breathing patients with acute circulatory failure: need for a cautious use. Critical Care 2012, 16:R188
  • Still need Takata 1990
  • Still need Takata 1990
  • Justin Bowra: IVC Filling: The Ultimate Myth

    1. 1. 1 IVC ultrasound: The Ultimate Myth Dr Justin Bowra Sydney Adventist & Royal North Shore Hospitals SMACC 2013 Thanks esp to Drs Kylie Baker & Adrian Goudie
    2. 2. IVC ultrasound: Holy Grail…
    3. 3. …or Wholly Nonsense?
    4. 4. The IVC The IVC
    5. 5. TThe inferior vena cava (IVC)he inferior vena cava (IVC)  Largest vein in the body.Largest vein in the body.  BBreathe in: diameter decreasesreathe in: diameter decreases  NB oNB opposite if ventilatedpposite if ventilated  DDehydration:ehydration: ‘‘flattens outflattens out’’..  DDownstream occlusion (eg tamponade) orownstream occlusion (eg tamponade) or fluid overload (eg CCF):fluid overload (eg CCF): ‘‘fattens upfattens up’’..
    6. 6. Subxiphoid longitudinal: shocked & drySubxiphoid longitudinal: shocked & dry
    7. 7. Subxiphoid transverse: massive PESubxiphoid transverse: massive PE
    8. 8. MMaybe the IVC can help me in the resus room.aybe the IVC can help me in the resus room. 1.1.IIs there fluid overload or a downstreams there fluid overload or a downstream occlusion (eg PE, tamponade)?occlusion (eg PE, tamponade)? 2.2.Should I give more IV fluids to this shockedShould I give more IV fluids to this shocked patient?patient?
    9. 9. WWhy is this an attractive idea?hy is this an attractive idea? CheapCheap EEasy to find & measureasy to find & measure NNoninvasiveoninvasive RRapidapid RRepeatableepeatable
    10. 10. ParametersParameters SShape (fat or flat?)hape (fat or flat?) MMaximum IVC diameter (IVCD)aximum IVC diameter (IVCD) IVC collapsibility index (IVCCI) = (maxIVC collapsibility index (IVCCI) = (max –– min)/maxmin)/max x100x100 RResponse toesponse to ‘‘sniff testsniff test’’
    11. 11. IVCCI (hypovolaemia) = 69%IVCCI (hypovolaemia) = 69%
    12. 12. IVCCI (CCF) = 10%IVCCI (CCF) = 10%
    13. 13. Critical care drs are now very, veryCritical care drs are now very, very iinterested in the IVCnterested in the IVC SStatementstatements TTextbooksextbooks Clinical aClinical algorithmslgorithms EExpertsxperts PPapersapers TTalks (like this one)alks (like this one) WWishful thinkingishful thinking
    14. 14. I WANT TO BELIEVE
    15. 15. I WANT TO BELIEVE
    16. 16. I WANT TO BELIEVE
    17. 17. IVC MYTHS
    18. 18. Myth 1: The IVC correlates with volume Status MEDSCAPE
    19. 19. Maximum IVC diameter (IVCD)
    20. 20. Dipti A et al. AJEM 2012 IVC diameter (not IVCCI) 140 papers  5 prospective trials Gold standard = clinical Dx shock IVCD lower in shocked patients All 5 studies agreed ‘Moderate level of evidence suggests that the IVC diameter is consistently low in hypovolemic status when compared with euvolemic.’
    21. 21. But wait a minute! IVC 14-15mm = shocked (2 studies) IVC 14-15mm = normal (3 studies) Why?
    22. 22.  Different ethnicity [Asian versus US/Turkish populations]?  Weekes and Yanagawa’s cases & ‘controls’ were the same patients  The IVCD improved after a fluid bolus and only when it was clinically obvious that the patient had improved!
    23. 23. So: IVCD <0.9cm correlates with haemorrhagic shock… in patients you can already tell are shocked. (Sefidbakht 2007, Yanagawa 2005, Weekes 2011) Serial IVCDs get bigger with fluids… in patients you can already tell are getting better. And if it stays <0.9cm after IVT, shock recurs in these patients. (Yanagawa 2007)
    24. 24. What about a big IVCD in the spontaneously breathing shocked patient?
    25. 25. What a big IVCD in the spontaneously breathing shocked patient? No-one knows.
    26. 26. What about ventilated patients? Do you like CVP as a surrogate for fluid status?
    27. 27. Small IVCDSmall IVCD IVCD <1.2cm suggests RAP <10mmHg. ( Jue J et al 1992)
    28. 28. What about a large IVCD? IVCD >2.5cm and minimal collapse (<10%) correlates with raised RAP (>15mmHg) = ‘the tank is full’. …probably. (Charron 2006: 100 patients)
    29. 29. So, in shocked patients: IVCD Correlation Spontaneously breathing <0.9cm Empty Anything else Dunno Ventilated <1.2cm Probably empty >2.5cm Probably full Or… PE/PTX/tampon ade Or… Other stuff that raises CVP
    30. 30. Okay, what about IVC collapsibility index? (IVCCI)
    31. 31. IVCCI in ventilated patients A minimal collapse (<10%) = raised RAP (>15mmHg) = ‘the tank is full’… maybe. (Charron 2006: 100 patients)
    32. 32. What about IVCCI in the patient sitting up? In breathless patients at 45 degrees: Low IVCCI <15% suggested clinical diagnosis of CCF. (Blehar et al, 2009) …and a high IVCCI? No-one knows.
    33. 33. What about shocked, spontaneouslyWhat about shocked, spontaneously breathing, supine patients?breathing, supine patients? IVCCI > 50% … CVP <8mm (Nagdev 2010) IVCCI <50% … CVP >10mm Hg (Kircher et al 1990) Gold standard?
    34. 34. BUT IVCCI Correlation Kircher <50% full Nagdev >50% empty Sefidbakht 27% shock 20% euvolaemic Weekes 16-72% shock 7-33% euvolaemic
    35. 35. So, in shocked patients: IVCCI Correlation Spontaneously breathing >72% Probably empty <16% Probably full Anything else Dunno Ventilated >10% Dunno <10% Probably full Or… PE/PTX/tampon ade Or… Other stuff that raises CVP
    36. 36. WHAT’S GOING ON? Big statements… From small studies.
    37. 37. (Maybe IVC just isn’t that precise)(Maybe IVC just isn’t that precise) MMaybe CVP ≠ fluid statusaybe CVP ≠ fluid status MMaybeaybe ‘‘fluid statusfluid status’’ = the wrong question.= the wrong question. So let’s try a new question!So let’s try a new question! Why is this so?
    38. 38. Myth 2: IVC ultrasound Can predict Fluid responsiveness LOTS OF AUTHORITIES
    39. 39. ‘‘The IVC can predict fluid responsiveness’The IVC can predict fluid responsiveness’  Empty IVC  IV fluids  improved end- organ perfusion  Full IVC  IV fluids won’t help  Logic: It makes sense.  Let’s look at the evidence
    40. 40. Low IVCD that stays low is usefulLow IVCD that stays low is useful Yanagawa 2007 So what about IVCCI?
    41. 41. Lanspa M et al. Shock 2013 Small study: 14 spontaneously breathing patients in septic shock, who had all received 2-5L IVT. Intervention: 10ml/kg fluid challenge. Gold standard: >15% increase in CI using TTE. An IVCCI <15% ruled out fluid responsiveness.
    42. 42. Muller L et al. Critical Care 2012 Small study: 40 spontaneously breathing patients with clinical signs of shock. Intervention: 500ml fluid challenge. Gold standard: >15% increase in CI using TTE. Their conclusion?
    43. 43. ‘IVCCI cannot reliably predict fluid responsiveness in spontaneously breathing patients with ACF.’ IVCCI >40% often associated with fluid responsiveness. Positive predictive value 72%.
    44. 44. In spontaneously breathing patients with shock: An IVCCI <15% seems to rule out fluid responsiveness (in a small study). IVCCI >40% often predicts fluid responsiveness (72% of the time)… in a small study. What about ventilated patients?
    45. 45. 3 small studies in ventilated patients: Barbier 2004: 23 patients: IVCCI >18% predicted fluid responsiveness (90% sens 90% spec) Feissel 2004: 39 patients: IVCCI >12% predicted fluid responsiveness (93% PPV and 92% NPV) Moretti 2010: 29 patients: IVCCI >16% was only 70% sensitive for fluid responsiveness!
    46. 46. So, can IVCCI predict fluid responsiveness in shocked patients? If spontaneously breathing: IVCCI <15% seems to rule out fluid responsiveness (in a small study). If ventilated: IVCCI >18% might predict fluid responsiveness (in 3 small studies).
    47. 47. Not great!
    48. 48. So let’s change the question (again).
    49. 49. Myth 3: IVC ultrasound Can predict Fluid tolerance WEINGART, ULTRASOUNDPODCAST, LOTS OF OTHERS
    50. 50. Surely it’s SAFE to give fluids if the IVC is flat? And maybe it’s BAD to give fluids if the IVC is distended? Well, it seems to make sense. And most of us follow this approach.
    51. 51. Surely it’s SAFE to give fluids if the IVC is flat? And maybe it’s BAD to give fluids if the IVC is distended? Well, it seems to make sense. And most of us follow this approach. But there’s no evidence for these statements.
    52. 52. Surely it’s SAFE to give fluids if the IVC is flat? And maybe it’s BAD to give fluids if the IVC is distended? Well, it seems to make sense. And most of us follow this approach. But there’s no evidence for these statements. And there’s evidence that IVC is affected by a number of other factors.
    53. 53. What else can splint the IVC open? Not just XS fluids Obstructive shock: tamponade, tension PTX, massive PE Raised intrathoracic pressure: e.g. status asthmaticus Chronic comorbidities: eg right heart disease Even probe position: too close to the diaphragm may ‘artificially reduce’ IVC collapse (Wallace 2010)
    54. 54. What else can cause the IVC to collapse? 1. Ventilation: Mechanical ventilation ≠ spontaneous ventilation ‘Diaphragmatic breathing’ (using abdominal wall muscles as well as the chest wall): (Kimura 2011) 2. Raised intra-abdominal pressure (in animal studies: Takata 1990) 3. Even pressure from the probe! (anecdotally)
    55. 55. Just because the IVC collapses, it doesn’t mean it’s safe to give fluids. Most of us do, but that’s not evidence.
    56. 56. IVC ultrasound commandment s
    57. 57. IVC diameter (cm) IVCCI Estimated RA pressure (mm Hg) <1.7 >50% 0-5 >1.7 >50% 6-10 >1.7 <50% 11-15 ‘dilated’ none >15 Commandment 1. THOU SHALT USE THIS TABLE ASE, ACEP, RUSH
    58. 58. IVC diameter (cm) IVCCI Estimated RA pressure (mm Hg) <1.7 >50% 0-5 >1.7 >50% 6-10 >1.7 <50% 11-15 ‘dilated’ none >15 ASE guidelines 2005
    59. 59. Not validated in critically ill patients.Not validated in critically ill patients. IVCD changes with patient position.IVCD changes with patient position. ED patients are either sitting up (SOB) or supineED patients are either sitting up (SOB) or supine (shock).(shock). ASE guidelines are based on patients in theASE guidelines are based on patients in the leftleft decubitusdecubitus position.position.
    60. 60. And it’s based on sonographers’ measurements.And it’s based on sonographers’ measurements. So?So?
    61. 61. IVC dimensions measured by clinicians don’t correlateIVC dimensions measured by clinicians don’t correlate with those measured by cardiac sonographers!with those measured by cardiac sonographers! Randazzo et al: 70.2% overall raw agreement in IVC measurements between EP (trained for 3h in focused cardiac US) and formal echocardiograms performed within 4h.
    62. 62. IVC diameter (cm) IVCCI Estimated RA pressure (mm Hg) <1.7 >50% 0-5 >1.7 >50% 6-10 >1.7 <50% 11-15 ‘dilated’ none >15 ASE guidelines 2005
    63. 63. IVC diameter (cm) IVCCI Estimated RA pressure (mm Hg) <1.7 >50% 0-5 >1.7 >50% 6-10 >1.7 <50% 11-15 ‘dilated’ none >15 ASE guidelines 2005
    64. 64. Commandment 2. Thou shalt Place the probe In subcostal long axis About Here. About Here. ASE, ACEP, stanford uni, ultrasoundpodcast
    65. 65. Or in the mid- Axillary line Just like A fast examACEP
    66. 66. What probe?What probe? What preset?What preset? Where?Where? Long or short axis?Long or short axis?
    67. 67. What probe should we use?What probe should we use? No-one knows.No-one knows.
    68. 68. What preset?What preset? No-one knows.No-one knows.
    69. 69. Where should we put the probe?Where should we put the probe? How should we align it?How should we align it?
    70. 70. Where should we put the probe?Where should we put the probe? How should we align it?How should we align it? NO-ONE KNOWS!NO-ONE KNOWS!
    71. 71. WhereWhere cancan we put the probe?we put the probe?  Subxiphoid long axis  Subxiphoid transverse  Midaxillary line long axis  Midaxillary line transverse  Transpyloric long axis  Transpyloric transverse
    72. 72. Subxiphoid long axis: most studies & experts measure here.
    73. 73. Subxiphoid short axis: RUSH, Akilli.
    74. 74. MID-AXILLARY LINE As for EFAST Midaxillary long axis: ACEP website recommends as an alternative.
    75. 75. Subcostal trans: MAX & MIN.Subcostal trans: MAX & MIN.
    76. 76. WatchWatch howhow the IVC collapses (subcostal)the IVC collapses (subcostal)
    77. 77. WatchWatch howhow the IVC collapses (RUQ)the IVC collapses (RUQ)
    78. 78. Short axis or long axis?Short axis or long axis?
    79. 79. Short axis pitfall:Short axis pitfall: IVC slides craniocaudally!IVC slides craniocaudally!
    80. 80. Long axis pitfall #1Long axis pitfall #1 cylinder effectcylinder effect
    81. 81. Long axis pitfall #1Long axis pitfall #1 cylinder effectcylinder effect
    82. 82. Long axis pitfall #2Long axis pitfall #2 IVC lateral movementIVC lateral movement
    83. 83. Subcostal long axis approach: probably OKSubcostal long axis approach: probably OK (if you’re careful).(if you’re careful). Midaxillary longitudinal approach: probablyMidaxillary longitudinal approach: probably not OK.not OK. Any transverse view: dunno.Any transverse view: dunno. But no-one’s really sure.But no-one’s really sure.
    84. 84. Commandment 3. Thou shalt Measure at the HVC confluence (JUST ABOUT EVERYONE)
    85. 85. Where should we measure the IVC?Where should we measure the IVC?
    86. 86. TThe IVC collapses non-uniformlyhe IVC collapses non-uniformly Site IVCCI At level of diaphragm 20% (+/- 16%) At hepatic vein inlet 30% (+/- 21%) At left renal vein 35% (+/- 22%) In supine healthy volunteersIn supine healthy volunteers Wallace et al, 2010Wallace et al, 2010
    87. 87. The IVC collapses non-uniformlyThe IVC collapses non-uniformly
    88. 88. The IVC collapses non-uniformlyThe IVC collapses non-uniformly
    89. 89. Which site is best?Which site is best? IVCCI measured above hepatic confluence does notIVCCI measured above hepatic confluence does not correlate with IVCCI measured at other sites.correlate with IVCCI measured at other sites. Wallace’s conclusion:Wallace’s conclusion: ‘‘Clinicians should avoidClinicians should avoid measuring IVCCImeasuring IVCCI at the junction ofat the junction of the right atrium and IVCthe right atrium and IVC’’
    90. 90. But there was no gold standard in thatBut there was no gold standard in that study.study. SSo how did Wallace know which siteo how did Wallace know which site was the right one?was the right one?
    91. 91. And it gets murkier:And it gets murkier: ASE recommends measuring 1-2cm from RA Yanagawa found a correlation (IVCD & RAP) just below diaphragm Charron found a correlation (IVCD & RAP) measured <2cm from RA Akilli (IVCD) & Blehar (IVCCI) found a correlation at / distal to hepatic veins Corl found no correlation (IVCI & CO) measured 3cm distal to the RA
    92. 92. So…So… We don’t even know where best to measure the IVC. Should we avoid measuring above the hepatic confluence? Should we insist on it?
    93. 93. Commandment 4. Try M-mode (RUSH, stanford university)
    94. 94. Should I measure in M-mode?Should I measure in M-mode? It’s lots of fun and displays both max & min diameterIt’s lots of fun and displays both max & min diameter on the same image.on the same image. Many experts (eg RUSH exam & Stanford Uni website)Many experts (eg RUSH exam & Stanford Uni website) recommend it.recommend it. I like it.I like it. But even experienced users can get the anglesBut even experienced users can get the angles wrong…wrong…
    95. 95. M-mode pitfalls:M-mode pitfalls: wrong angle, and IVC moveswrong angle, and IVC moves
    96. 96. TTop tip:op tip: When starting out, aWhen starting out, avoid M-mode.void M-mode.
    97. 97. Commandment 5. Try A sniff test (ASE, RUSH)
    98. 98. SSniff test (great in healthy volunteers)niff test (great in healthy volunteers)
    99. 99. Should I perform a sniff test?Should I perform a sniff test? RUSH exam & American Society of Echo recommendsRUSH exam & American Society of Echo recommends it.it. But I can’t find any evidence for it.But I can’t find any evidence for it. And half the time I lose sight of the IVC when theAnd half the time I lose sight of the IVC when the patient sniffs!patient sniffs! And I can’t help thinking…And I can’t help thinking…
    100. 100. If the patient is well enough to perform aIf the patient is well enough to perform a sniff test, I probably don’sniff test, I probably don’t need to bet need to be looking at their IVC.looking at their IVC.
    101. 101. IVC ultrasound: what do we really know?IVC ultrasound: what do we really know?
    102. 102. IVC ultrasound: what do we really know?IVC ultrasound: what do we really know?  WWee dondon’’tt know where to measure itknow where to measure it……
    103. 103. IVC ultrasound: what do we really know?IVC ultrasound: what do we really know?  WWee dondon’’tt know where to measure itknow where to measure it …… oror eveneven howhow to measure it!to measure it!
    104. 104. IVC ultrasound: what do we really know?IVC ultrasound: what do we really know?  WWee dondon’’tt know where to measure it, or evenknow where to measure it, or even how to measure it!how to measure it!  WWee dondon’’tt know if a sniff test helps.know if a sniff test helps.
    105. 105. IVC ultrasound: what do we really know?IVC ultrasound: what do we really know?  WWee dondon’’tt know where to measure it, or evenknow where to measure it, or even how to measure it!how to measure it!  WWee dondon’’tt know if a sniff test helps.know if a sniff test helps.  WWe know that ASE table is probably useless.e know that ASE table is probably useless.
    106. 106. IVC ultrasound: what do we really know?IVC ultrasound: what do we really know?  WWee dondon’’tt know where to measure it, or evenknow where to measure it, or even how to measure it!how to measure it!  WWee dondon’’tt know if a sniff test helps.know if a sniff test helps.  WWe know that ASE table is probably useless.e know that ASE table is probably useless.  WWe know everyonee know everyone’’s IVC is different, and thats IVC is different, and that there are plenty of confounding factorsthere are plenty of confounding factors……
    107. 107. IVC ultrasound: what do we really know?IVC ultrasound: what do we really know?  WWee dondon’’tt know where to measure it, or howknow where to measure it, or how to measure it.to measure it.  WWee dondon’’tt know if a sniff test helps.know if a sniff test helps.  WWe know that ASE table is probably useless.e know that ASE table is probably useless.  WWe know everyonee know everyone’’s IVC is different, and thats IVC is different, and that there are plenty of confounding factorsthere are plenty of confounding factors…… Patient size & positionPatient size & position Manner of breathingManner of breathing Measurement siteMeasurement site EtcEtc
    108. 108. IVC ultrasound: what do we really know?IVC ultrasound: what do we really know? Shock + flat collapsing IVC = give fluid.Shock + flat collapsing IVC = give fluid. <0.9cm (spontaneous breathing)<0.9cm (spontaneous breathing) <1.2cm IVCD, IVCCI >18% (ventilated)<1.2cm IVCD, IVCCI >18% (ventilated) Shock + distended IVC = don’t give fluid.Shock + distended IVC = don’t give fluid. >2.5cm, IVCCI <10% (ventilated)>2.5cm, IVCCI <10% (ventilated) SSerial IVC measurements seem useful.erial IVC measurements seem useful.
    109. 109. IVC ultrasound: what do we really know?IVC ultrasound: what do we really know? Shock + flat collapsing IVC = give fluid.Shock + flat collapsing IVC = give fluid. <0.9cm (spontaneous breathing)<0.9cm (spontaneous breathing) <1.2cm IVCD, IVCCI >18% (ventilated)<1.2cm IVCD, IVCCI >18% (ventilated) Shock + distended IVC = don’t give fluid.Shock + distended IVC = don’t give fluid. >2.5cm, IVCCI <10% (ventilated)>2.5cm, IVCCI <10% (ventilated) SSerial IVC measurements seem useful.erial IVC measurements seem useful. MAYBE
    110. 110. ‘The IVC is the answer’
    111. 111. But I tried it And it didn’t work And the sniff Test seems like A waste of time
    112. 112. You mustn’t be doing it right
    113. 113. Or maybe it’s a load of cobblers
    114. 114. The dark art of IVC measurement. ‘Give a bolus of fluid’ …I think
    115. 115. Take-home message Check the evidenceCheck the evidence yourselfyourself before you changebefore you change your practice.your practice. Be a doctor. Clinical context is more important thanBe a doctor. Clinical context is more important than IVC ultrasound.IVC ultrasound. IVC probably does help at extremes (fat & fullIVC probably does help at extremes (fat & full versus flat & collapsing).versus flat & collapsing).
    116. 116. Thanks toThanks to Dr Kylie Baker (for that literature review) Dr Adrian Goudie (for that IVC long axis image) Drs Mike Blaivas, Matt Dawson, Cliff Reid & Scott Weingart (for their advice & input)
    117. 117. ReferencesReferences  ACEP http://www.acep.org/Content.aspx?id=80791  Akilli B, Bayir A et al. Inferior vena cava diameter as a marker of early hemorrhagic shock: a comparative study. Ulus Travma Acil Cerrahi Derg 2010;16(2):113-8.  Baker, K. Review of Bedside Sonography for Guidance of Fluid Therapy in the Emergency Department. (unpublished)  Barbier C, Loubières Y, Schmit C, Hayon J, Ricôme JL, Jardin F, Vieillard-Baron A. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid respon- siveness in ventilated septic patients. Intensive Care Med 2004; 30:1740–1746  Blehar DJ, Dickman E, Gaspari R. Identification of congestive heart failure via respiratory variation of inferior vena cava. Am J Em Med 2009;27:71–5.  Blehar et al. Inferior vena cava displacement during respirophasic ultrasound imaging. Critical Ultrasound Journal 2012, 4:18
    118. 118. ReferencesReferences  Charron C, Caille V, Jardin F, Viellard-Baron A. Echocardiographic measurement of fluid responsiveness. Curr Op Crit Care 2006; 12(3): 249-54.  Corl K, Napoli A, Gardiner F. Bedside sonographic measurement of the inferior vena cava caval index is a poor predictor of fluid responsiveness in emergency department patients. Emergency Medicine Australasia (2012) 24, 534–539  Dipti A et al. Role of inferior vena cava diameter in assessment of volume status: a meta-analysis. AJEM 2012 (30). 1414 -19.  Feissel M, Michard F, Faller JP, Teboul JL (2004) The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Med 30:1834–1837  Jue J, Chung W, Schiller NB. Does inferior vena cava size predict right atrial pressures in patients receiving mechanical ventilation. J Am Soc Echocardiogr 1992; 5: 613-9.
    119. 119. ReferencesReferences  Kimura BJ, Dalugdugan R, Gilcrease GW 3rd, Phan JN, Showalter BK, Wolfson T. The effect of breathing manner on inferior vena caval diameter. Eur J Echocardiogr. 2011 Feb;12(2):120-3  Kircher B, Himelman R, Schiller N. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. AM J Cardiol 1990; 66: 493-6.  Lang RM, Bierig M, Devereux F et al Recommendations for chamber quantification: a report from the American Society of Echocardiography’s guidelines and standards committee and the chamber quantification writing group, developed in conjunction with the European Association of Echocardiography, ad branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005; 18: 1440-63.  Lanspa MJ, Grissom CK et al. Applying dynamic parameters to predict hemodynamic response to volume expansion in spontaneously breathing patients with septic shock. Shock 2013. 39(2). pp. 155-160
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