The IVC is Trash

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Matthew Tyler
Critical Care and Emergency doc in Chicagoland. Minimalist Intensivist. Advanced echo ultrasonographer. Proceduralist. ChoosingWisely advocate. Health policy wonk. I make damn good pasta. Urban gardener

The Pre-brief

Ultrasound of the inferior vena cava (IVC) provides very little benefit in evaluating a patient’s fluid status.

The IVC is Trash (for volume assessment)

This will certainly come as a shock to many clinicians who for years have casually placed a probe on a patient’s epigastrium and based on IVC collapsibility concluded that the patient either needed fluids or was adequately ‘tanked up.’ Doesn’t that seem too easy? The human body is about 60% water with fluid distribution managed by multiple organs and gradients influenced by electrolyte and protein concentrations. In critically ill patients, capillary leakage, vasoplegia, post-surgical status, vasopressors and/or mechanical ventilatory support can further complicate the picture. The IVC’s collapsibility with respirations has been considered the key to estimating fluid status, but the tidal volumes in spontaneously breathing patients, especially critically ill patients, change from breath to breath. There are just too many variables affecting IVC collapsibility for it to be a reliable tool to assist with determining fluid status and fluid responsiveness.

There are, however, some uncommon clinical scenarios where IVC respirovariability, when combined with the evaluation of a patient’s biomarkers, echocardiogram, physical exam, vitals, pulmonary status, and presenting symptoms, can contribute to the fluid status assessment 

1) The IVC almost entirely collapses with respirations. This MAY indicate an under-resuscitated, hypovolemic patient.

2) The IVC is plethoric with minimal respirovariability. This MAY indicate a resuscitated or even hypervolemic patient.

3) The patient is compliant on a ventilator with no patient-triggered breaths and is receiving at least 8 cc/kg tidal volume. This is an uncommon occurrence and present in only ~2% of patients in an Intensive Care Unit. However, if present, the IVC distensibility index can be used: IVCmax diameter  – IVCmin diameter  / IVCmax diameter x 100. If this value is >12-18%, then the patient MAY be fluid responsive.

The IVC, despite its limitations in measuring fluid status and fluid responsiveness, remains useful in calculating pulmonary artery systolic and diastolic pressures, ruling out tamponade physiology, and confirming device placement.

The Debrief

  • Use ultrasound of the IVC in conjunction with other variables (labs, exam, vitals, pulmonary status, thoracic ultrasound, echocardiography & LVOT VTI) to help determine fluid status and fluid responsiveness and whether or not a patient needs crystalloid.
  • IVC respirovariability by itself is a poor tool for determining fluid status
  • Ultrasound of the IVC is more useful for PA pressure calculations, ruling out cardiac tamponade, and confirming device placement.

References

  1. Corl K, Napoli AM, 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 Oct;24(5):534-9.
  2. Kory P. COUNTERPOINT: should acute fluid resuscitation be guided primarily by inferior vena cava ultrasound for patients in shock? No. Chest. 2017 Mar 1;151(3):533-6.
  3. Sobczyk D, Nycz K, Andruszkiewicz P, Wierzbicki K, Stapor M. Ultrasonographic caval indices do not significantly contribute to predicting fluid responsiveness immediately after coronary artery bypass grafting when compared to passive leg raising. Cardiovascular ultrasound. 2015 Dec;14(1):1-8.
  4. Juhl-Olsen P, Vistisen ST, Christiansen LK, Rasmussen LA, Frederiksen CA, Sloth E. Ultrasound of the inferior vena cava does not predict hemodynamic response to early hemorrhage. The Journal of emergency medicine. 2013 Oct 1;45(4):592-7.
  5. Resnick J, Cydulka R, Platz E, Jones R. Ultrasound does not detect early blood loss in healthy volunteers donating blood. The Journal of emergency medicine. 2011 Sep 1;41(3):270-5.
  6. de Valk S, Olgers TJ, Holman M, Ismael F, Ligtenberg JJ, Ter Maaten JC. The caval index: an adequate non-invasive ultrasound parameter to predict fluid responsiveness in the emergency department?. BMC anesthesiology. 2014 Dec;14(1):1-6.
  7. Field S, Hockstein M, Garber B. Hemodynamic Monitoring Modalities in the Emergency Department. Emergency Medicine Reports. 2017 Oct 1;38(20).
  8. Tyler MD, Arntfield R, Roy A, Mallemat H. Inferior Vena Cava. Point of Care Ultrasound E-book. 2019 Apr 26:145.
  9. 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 responsiveness in ventilated septic patients. Intensive care medicine. 2004 Sep;30(9):1740-6.
  10. Feissel M, Michard F, Faller JP, Teboul JL. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive care medicine. 2004 Sep;30(9):1834-7.
  11. Machare-Delgado E, Decaro M, Marik PE. Inferior vena cava variation compared to pulse contour analysis as predictors of fluid responsiveness: a prospective cohort study. Journal of intensive care medicine. 2011 Mar;26(2):116-24.
  12. Moretti R, Pizzi B. Inferior vena cava distensibility as a predictor of fluid responsiveness in patients with subarachnoid hemorrhage. Neurocritical care. 2010 Aug 1;13(1):3-9.
  13. Mahjoub Y, Lejeune V, Muller L, Perbet S, Zieleskiewicz L, Bart F, Veber B, Paugam-Burtz C, Jaber S, Ayham A, Zogheib E. Evaluation of pulse pressure variation validity criteria in critically ill patients: a prospective observational multicentre point-prevalence study. British journal of anaesthesia. 2014 Apr 1;112(4):681-5.
  14. Maguire S, Rinehart J, Vakharia S, Cannesson M. Respiratory variation in pulse pressure and plethysmographic waveforms: intraoperative applicability in a North American academic center. Anesthesia & Analgesia. 2011 Jan 1;112(1):94-6.

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