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Intensive Care Medicine

, Volume 42, Issue 7, pp 1164–1167 | Cite as

Ten situations where inferior vena cava ultrasound may fail to accurately predict fluid responsiveness: a physiologically based point of view

  • G. ViaEmail author
  • G. Tavazzi
  • S. Price
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Introduction

Assessment of the size of the inferior vena cava (IVC) and its change in diameter in response to respiration have been investigated as a tool to screen for severe hypovolaemia [ 1], predict fluid responsiveness (FR) [ 2, 3] and assess potential intolerance to fluid loading. IVC size, collapsibility (IVCc) [ 2] and distensibility (IVCd) [ 3] have gained acceptance by emergency and intensive care unit (ICU) clinicians as FR predictors in patients with shock [ 4]. The ease of acquisition, reproducibility of measurements and increasing availability of ultrasound devices have supported the expansion of its use. Conflicting results have also been published [ 5, 6]. Injudicious application in clinical contexts where these indices have not been specifically tested may, however, mislead. On the basis of physiological principles and available, although limited, scientific evidence, it can be hypothesized that in a number of clinical conditions IVC size and/or respiratory variability may...

Keywords

Right Ventricular Inferior Vena Cava Fluid Responsiveness Right Atrial Pressure Inferior Vena Cava Pressure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Compliance with ethical standards

Conflicts of interest

None of the authors has any conflict to declare.

Supplementary material

Clip 1-ESM. Patient with moderate ARDS, paralyzed, ventilated in pressure control modality (PCV) with high PEEP levels. In sequence: apical 4-chamber view (A4Ch) shows a hyperdynamic left ventricle and RV systolic dysfunction (the ratio between the area of the RV and that of the LV, RVEDA/LVEDA, is 1); ventilator curves and parameters suggest a reduced respiratory system compliance (31 ml/cmH2O is the value obtained with static measurements). Ventilation is set with an I/E equal to 1:1. Small tidal volumes are consistent with a lung-protective ventilation strategy. Inferior vena cava inspiratory size change would indicate absence of fluid responsiveness (IVCd index < 18 %). However, dynamic assessment with a pulse-contour cardiac output monitoring (Vigileo™) reveals a significant increase in cardiac index following administration of a fluid bolus (500 ml crystalloids; arrow indicates beginning of the fluid challenge) (MOV 20864 kb)

134_2016_4357_MOESM2_ESM.mov (15.9 mb)
Clip 2-ESM. Inferior vena cava in a patient ventilated with pressure support ventilation (PSV). Pressure and flow ventilator curves exhibit a significant active inspiratory effort. Inferior vena cava ultrasound (IVC, subcostal long axis view) shows consistent IVC size reduction in the first phase of the inspiration, followed by a size increase in the second phase when positive pressure exerted by the ventilator prevails. A zoomed slow-motion view at the end of the clip highlights the two phases of the inspiration, with IVC size reduction (white arrow) and increase (yellow arrow). IVC-based Fluid responsiveness indices, validated in patients either in spontaneous breathing or completely passive ventilation, are in this situation clearly not applicable (MOV 16310 kb)

Clip 3-ESM. Patient with acute pulmonary oedema in respiratory distress. First spontaneously breathing and then mechanically ventilated. In sequence: subcostal inferior vena cava view (SIVC) shows a dilated IVC with great inspiratory size reduction (IVCc index 70 %), hence potentially predictive of fluid responsiveness. Subsequent SIVC view, taken immediately after an uneventful patient intubation, conversely shows similar IVC size but completely absent distensibility, suggestive of absent volume responsiveness (patient ventilated with PCV modality, PEEP = 10 cmH2O, Psupp 13 cmH2O). No fluid bolus was administered between the two scans. A passive leg raising test (PLR) assessed with pulsed-wave Doppler sampling of left ventricular outflow tract (LVOT) yielded at this a time a conclusive negative result: a negligible increase of LVOT VTI is shown (PLR: 7 % VTI increase, from 14 cm to 15 cm). Had the patient really been fluid responsive when the positive IVCc index was obtained, the shift to positive pressure ventilation would have confirmed/increased the patient’s fluid responsiveness observed in spontaneous respiration. Both IVCd index and the PLR test during mechanical ventilation conversely ruled out FR. This suggests that the wide IVC size respiratory excursions in spontaneous respiration were rather caused by the great inspiratory effort of the patient. As a side note, a small localized pericardial effusion is also visible between the right chambers and the liver (MOV 16085 kb)

Clip 4-ESM. Respiratory pattern and inferior vena cava ultrasound in a spontaneously breathing patient with acute asthma. At admission the patient presented respiratory distress associated with marked wheezing. His breathing pattern entailed deep inspirations and forced exhalations; this is manifested by pronounced contraction of abdominal muscles at expiration and is associated with a paradoxical respiratory variation of inferior vena cava (IVC) size (i.e. an expiratory collapse during spontaneous breathing). Clips and videos present simultaneous subcostal IVC views of the patient’s breathing pattern. Some hours after effective bronchodilator therapy, forced expiration had nearly disappeared. Relevant inspiratory effort was still made by the patient, and the IVC shows inspiratory collapsibility at this time (MOV 15564 kb)

Clip 5-ESM. Spontaneously breathing septic patient with chronic pulmonary hypertension, at ICU admission. In sequence: apical 4-chamber (A4Ch) and parasternal short axis views (PSAX) show a dilated and hypokinetic RV, compressing the LV; subcostal long axis view (SLAX) shows also hypertrophy of the RV free wall (yellow arrow); subcostal inferior vena cava view (SIVC) indicates small inspiratory size reduction of the IVC (negative IVCc index). Despite this, left ventricular outflow tract pulsed-wave Doppler sampling demonstrates an increase in stroke volume and cardiac output after repeated fluid challenges (total 750 ml of crystalloids) (MOV 14083 kb)

Clip 6-ESM. Patient with RV acute myocardial infarction and cardiogenic shock, mechanically ventilated in pressure control modality (PCV). In sequence: subcostal long axis view (SLAX) shows a pattern of severe RV failure: the RV is extremely dilated (the ratio between the area of the RV and that of the LV, RVEDA/LVEDA, is >1) and dramatically hypokinetic; the RV is compressing the LV and severely interferes with its filling. Subcostal inferior vena cava view (SIVC) highlights negligible respiratory distensibility of the vessel (IVCd < 18 %), i.e. a negative prediction for fluid responsiveness. On the basis of the pathophysiology of haemodynamic instability in RV myocardial infarction, 1000 ml of ringer acetate was progressively administered over 1 h. Subsequent SLAX shows an equally failing RV, but a better filled LV; SIVC view highlights persistence of a fixed, dilated IVC, which now appears even larger. Dynamic assessment with pulse-contour cardiac output monitoring (Vigileo™) confirmed a significant increase in stroke volume and cardiac index as result of the fluid bolus (arrow indicates the start of fluid bolus administration). As a side note, the hyperechoic structure floating in the RV and IVC is the wire of a temporary pacemaker (MOV 19584 kb)

Clip 7-ESM. Patient with cardiac tamponade caused by pericardial metastatic disease, spontaneously breathing. In sequence: subcostal long axis view (SLAX) shows a large circumferential pericardial effusion, a “swinging heart”, and clear signs of compression of the low-pressure heart chambers (RV wall diastolic inward displacement, RA wall systolic inward displacement). Subcostal inferior vena cava view (SIVC) confirms the diagnosis by highlighting IVC plethora, a hallmark of systemic venous congestion in tamponade. While the patient waited for a resolving emergent pericardiocentesis, a bolus of 500 ml hetastarch was administered, with a beneficial increase of non-invasive blood pressure from 70/50 mmHg to 85/55 mmHg and slight improvement in patients symptoms (MOV 13907 kb)

Clip 8-ESM. Inferior vena cava containing two ECMO cannulae in a patient supported with vv-ECMO with femoro-femoral access (patient ventilated in assisted modality, PSV). In sequence: subcostal inferior vena cava views in long axis (SIVC long) and short axis (SIVC short) cuts show the side-by-side presence of two cannulae (arrowṡ). They completely occupy the lumen of the vessel and clearly prevent the vessel’s inspiratory size reduction upon patient’s inspiration (MOV 16858 kb)

Clip 9-ESM. Patient manifesting marked inspiratory lateral translation of the inferior vena cava, generating a misleading, apparent, inspiratory collapse of the vessel (spontaneous respiration). In sequence: subcostal inferior vena cava (SIVC long) view shows a large inspiratory size reduction of the vessel. A transverse cut (SIVC short) at the same level conversely highlights an absence of respiratory variations of the IVC, unmasking the pitfall. Subsequent dynamic adjustment of the scanning plane during inspiration allows one to maintain a sagittal cut of the IVC throughout the entire respiratory cycle (SIVC long adjusted alignment). This finally leads to a correct interpretation of the ultrasound picture, depicting a negative IVC collapsibility index (MOV 23103 kb)

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Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2016

Authors and Affiliations

  1. 1.Anesthesia, Intensive Care, and Emergency DepartmentFondazione Policlinico San Matteo IRCCSPaviaItaly
  2. 2.Anesthesia, Intensive Care and Pain TherapyUniversity of PaviaPaviaItaly
  3. 3.Adult Intensive CareRoyal Brompton and Harefield NHS Foundation TrustLondonUK

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