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Three Part Question

In [critically ill patients in ED] can [inferior vena cava (IVC) diameter] correlate with [fluid assesssment]?

Clinical Scenario

A 65 yrs old gentleman presented to the ED with Acute SOB and high temperature with previous history of LVF. Will IVC diameter help decide whether we need to give or restrict fluids to treat him?

Search Strategy

Medline
Embase 1980- may 2011
Amed 1985- May 2011
Cinhal 1981- May 2011
Cochrane
Google scholar
(inferior AND vena AND cava AND for AND fluid AND resuscitation).ti,ab
(inferior AND vena AND cava AND for AND fluid AND assessment).ti,ab

Search Outcome

total 9 papers were retrieved and among them 3 were found relevant to 3 part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kosiak et al, 2008, Poland	52 healthy volunteers had IVC/Aortic index measured at fasting and 8hrs after 1500-2000ml of fluid. This IVC/Aortic index was compared with IVC/Aortic index of 7 pts with Hemolytic Uraemic Syndrome, Acute Renal Failure, Nephrotic syndrome and pericarditis to estimate the treatment response.	Diagnostic, comparative, prospective, single center study.	IVC/Aortaindex as a convenient way of evaluating body fluid status.	IVC/Ao index is very useful parameter in estimating body fluid status	Single center, selection bias, small number,training issues.
Brendan et al, 2007, Pennsylvania	70 patients from Surgical Intensive Care Unit had cardiac US and IVC diameter measured for volume assessment (Hypovolemic and Not hypovolemic). The reference standard was expert clinical judgment of pts volume status made by the Intensivists.	Prospective cross sectional, single blinded study of convenience sample.	The bedside US is a very feasible,potentially usefull and readily availabe modality.	The concordance rate between ECJ and cardiac US was 75% (p=0.11)	Small sample, convenience sample, selection bias, single center, no documentation of inter observer reliability(kappa score). No pt follow up documented.
				The concordance rate between ECJ and IVC collapse index was 65%(p=0.72)
				The concordance rate between (ECJ)expert clinical judgment and IVC diameter was 67% (p= 0.56)
				The concordance rate between ECJ and CVP was 62%
Stawicki et al, 2009, Philadelphia	124 surgical intensive care patients had IVC assessment and evaluation of left ventricular ejection fraction, mitral valve inflow, tissue doppler measurements and cardiac filling done.	Prospective, diagnostic, single center study.	To compare intensivist performed IVC evaluation (IVC-CI)with invasive CVP monitoring to determine how well they correlate.	The mean CVP values were inversely proportional to the IVC-CI (IVC collapsibility index).	Small number, single center, selection bias, no documentation of inter observer reliabilty score(kappa).
				Pts with IVC-CI <0.20 the mean CVP was 12mm Hg
				In pts with IVC-CI >0.60 the mean CVP was 7.4mm Hg was
				In pts with IVC-CI 0.20-0.60 the mean CVP was 9 mm HG
				bedside IVC assessment(IVC-CI)can offer the treating clinician a rapid, easily repeated and non invasive adjunct in the assessment and management of critically ill patients.

Comment(s)

There isnt a great level of evidence available(level 3 and 4) in the literature but a large multicenter, double blinded study will be helpful to validate theses studies.

Clinical Bottom Line

In view of available evidence ED ultrasound guided IVC diameter measurement is potentially a quick , easy and non invasive method for volume assessment in critically ill and trauma patients.

References

1. Kosiak W, Swieton D, Piskunowicz M. Sonographic inferior vena cava/ aortic diameter index, a new approach to the body fluid status assessmentin children and young adults in emergency ultrasound. American journal of emergency medicine 2008, 26, 320-325.
2. Carr BG, Dean AJ, Everett WW et al. Intensivist bedside US for volume assessment in intensive care unit. the Journal of trauma 2007, 63: 495-502.
3. Stawicki SP, Braslow BM, Panebianco NL et al. Intensivist Use of hand carried US to measure IVC collapsibility in estimating intravascular volume status: correlation with CVP. J Am Coll Surg 2009 , vol 209 55-61.