Journal of Clinical Monitoring and Computing

, Volume 31, Issue 5, pp 919–926 | Cite as

Intraoperative TTE inferior vena cava monitoring in elderly orthopaedic patients with cardiac disease and spinal-induced hypotension

  • Theodosios SaranteasEmail author
  • Dimitrios Manikis
  • Thomas Papadimos
  • Andreas F. Mavrogenis
  • Georgia Kostopanagiotou
  • Fotios Panou
Original Research


Objective To address the role of transthoracic echocardiography in inferior vena cava (IVC) monitoring in the management of haemodynamically unstable elderly patients subjected to lower limb orthopaedic surgery under spinal anesthesia. Possible implications in the postoperative care unit (PACU) length of stay (LOS) are investigated. Methods 41 elderly patients with cardiac diseases were recruited. Patients experiencing intraoperative haemodynamic instability (diastolic blood pressure ≤ 60 mmHg) were divided into two groups according to right atrial pressure (RAP), (RAP < 5 mmHg and RAP between 5 and 10 mmHg) as measured by inferior vena cava collapsibility index (IVCCI). Haemodynamic instability was treated with normal saline infused at a constant rate supplemented by phenylephrine (PHE) infusions titrated to normal blood pressure values. Intraoperatively comparisons of peak PHE infusion rates and all episodes of hypotension, including in the PACU, were recorded among groups. The patients’ PACU LOS and associated factors were assessed. Results The intraoperative peak PHE infusion rate and the incidence of haemodynamic instability in the postoperative period were significantly higher in patients with RAP < 5 mmHg. The total PHE consumption was also higher in patients with RAP < 5 mmHg postoperatively. The primary risk factor for a prolonged stay in PACU, as determined by multiple regression analysis was RAP. Conclusions Patients with high dynamic collapsibility of the IVC may require aggressive treatment to restore their haemodynamic status. Additionally, intraoperative levels of RAP, as measured by IVCCI, can act as a predictor for increased LOS in the PACU.


TTE Inferior vena cava PACU Spinal anesthesia 



American college of cardiology


American heart association


Body mass index


Central venous pressure


Diastolic blood pressure


Ejection fraction




Heart rate


Inferior vena cava




Inferior vena cava collapsibility index


Left ventricle


Length of stay


New York heart association


Post-anesthesia care unit




Postoperative nausea and vomiting


Right atrial pressures


Right ventricle


Tricuspid annular plane systolic excursion


Transthoracic echocardiography


Compliance with ethical standards

Conflict of interest

No benefits have been or will be received from a commercial party related directly or indirectly to the subject matter of this article. We wish also to confirm that there is no financial support for this work that could have influenced its outcome.


  1. 1.
    Tarkkila PJ, Kaukinen S. Complications during spinal anesthesia: a prospective study. Reg Anesth. 1999;16(2):101–6.Google Scholar
  2. 2.
    Tsui BC, Wagner A, Finucane B. Regional anesthesia in the elderly: a clinical guide. Drugs Aging. 2004;21:890–5.CrossRefGoogle Scholar
  3. 3.
    Stern S, Behar S, Gottlieb S. Aging and diseases of the heart. Circulation. 2003;108:e99–101.CrossRefPubMedGoogle Scholar
  4. 4.
    Papanikolaou J, Makris D, Karakitsos D, Saranteas T, Kostopanagiotou G, Zakynthinos D. Cardiac and central vascular functional alterations in the acute phase of aneurysmal subarachnoid hemorrhage. Crit Care Med. 2012;40(1):223–32.CrossRefPubMedGoogle Scholar
  5. 5.
    Saranteas T, Alevizou A, Tzoufi M, Panou F, Kostopanagiotou G. Transthoracic echocardiography for the diagnosis of left ventricular thrombosis in the postoperative care unit. Crit Care. 2011;15(1):54.CrossRefGoogle Scholar
  6. 6.
    Saranteas T, Kostopanagiotou G, Tzoufi M, et al. Incidence of inferior vena cava thrombosis detected by transthoracic echocardiography in the immediate postoperative period after adult cardiac and general surgery. Anaesth Intensive Care. 2013;41(6):782–7.PubMedGoogle Scholar
  7. 7.
    Brennan JM, Blair JE, Goonewardena S, et al. Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr. 2007;20:857–61.CrossRefPubMedGoogle Scholar
  8. 8.
    Via G, Tavazzi G, Price S. Ten situations where inferior vena cava ultrasound may fail to accurately predict fluid responsiveness: a physiologically based point of view. Intensive Care Med. 2016;42(7):1164–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Lalani SB, Ali F, Kanji Z. Prolonged-stay patients in the PACU: a review of the literature. J Perianesth Nurs. 2013;28:151–5.CrossRefPubMedGoogle Scholar
  10. 10.
    Vimlati L, Gilsanz F, Goldik Z. Quality and safety guidelines of postanesthesia care: working party on post anesthesia care (approved by the European board and section of anaesthesiology, Union Européenne des Médecins Spécialistes). Eur J Anaesthesiol. 2009;26:715–21.CrossRefPubMedGoogle Scholar
  11. 11.
    Yancy CW, Jessup M, Bozkurt B, et al. ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147–239.CrossRefPubMedGoogle Scholar
  12. 12.
    Gao L, Zheng G, Han J, Wang Y, Zheng J. Effects of prophylactic ondansetron on spinal anesthesia-induced hypotension: a meta-analysis. Int J Obstet Anesth. 2015;24(4):335–43.CrossRefPubMedGoogle Scholar
  13. 13.
    Larsen KA, Kelly SE, Stern TA, et al. Administration of olanzapine to prevent postoperative delirium in elderly joint-replacement patients: a randomized, controlled trial. Psychosomatics. 2010;51(5):409–18.CrossRefPubMedGoogle Scholar
  14. 14.
    Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16(3):233–720.CrossRefPubMedGoogle Scholar
  15. 15.
    Saranteas T, Panou F, Manikis D, Mavrogenis A, Kostopanagiotou G, Papadimos T. Pocket-sized transthoracic echocardiography for intraoperative monitoring of heart function in spontaneously breathing patients and the optimal acoustic window. Br J Anaesth. 2016;116(4):556–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Rudski LG, Lai WW, Afilalo J, et al. Guide lines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685–713.CrossRefPubMedGoogle Scholar
  17. 17.
    Critchley LAH, Stuart JC, Short TG, Gin T. Haemodynamic effects of subarachnoid block in elderly patients. Br J Anaesth. 1994;73:464–70.CrossRefPubMedGoogle Scholar
  18. 18.
    Heesen M, Stewart A, Fernando R. Vasopressors for the treatment of maternal hypotension following spinal anesthesia for elective caesarean section: past, present and future. Anesthesia. 2015;70(3):252–7.CrossRefGoogle Scholar
  19. 19.
    McCrae AF, Wildsmith JA. Prevention and treatment of hypotension during central neural block. Br J Anaesth. 1993;70(6):672–80.CrossRefPubMedGoogle Scholar
  20. 20.
    Feigenbaum H. The echocardiographic examination. In: Feigenbaum H, Armrstrong WF, Ryan T, editors. Feigenbaums’s Echocardiography. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 107–9.Google Scholar
  21. 21.
    Vieillard-Baron A, Charron C, Chergui K, Peyrouset O, Jardin F. Bedside echocardiographic evaluation of hemodynamics in sepsis: is a qualitative evaluation sufficient? Intensive Care Med. 2006;32:1547–52.CrossRefPubMedGoogle Scholar
  22. 22.
    Chung F. Risk factors for prolonged stay after ambulatory surgery: economic considerations. Curr Opin Anaesthesiol. 2002;15(2):245–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Huchet AM, Chelly J, Schmitt H. Role of alpha 1- and alpha 2-adrenoceptors in the modulation of the baroreflex vagal bradycardia. Eur J Pharmacol. 1981;71(4):455–61.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2016

Authors and Affiliations

  • Theodosios Saranteas
    • 1
    • 5
    Email author
  • Dimitrios Manikis
    • 1
  • Thomas Papadimos
    • 4
  • Andreas F. Mavrogenis
    • 2
  • Georgia Kostopanagiotou
    • 1
  • Fotios Panou
    • 3
  1. 1.Second Department of AnesthesiologyAthens University Medical SchoolAthensGreece
  2. 2.First Department of OrthopaedicsAthens University Medical SchoolAthensGreece
  3. 3.Second Department of CardiologyAthens University Medical SchoolAthensGreece
  4. 4.Department of AnesthesiologyThe Ohio State University, Weaxner Medical CenterColumbusUSA
  5. 5.AthensGreece

Personalised recommendations