Ivc guided fluid management in the icu
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A lecture on Inferior Vena Cava Guided fluid resuscitation in the Critically ill patients.
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Ivc guided fluid management in the icu
- 1. IVC-Guided Fluid Management in the ICU DR. HATEM A. SOLIMAN, MSC, MRCP MAFRAQ HOSPITAL CRITICAL CARE CME PROGRAM
- 2. Outline • Anatomy • Physiology • Main Idea • Procedure • Pearls & Pitfalls • Take home message • References • Useful Resources
- 4. Anatomy
- 5. Anatomy • The IVC returns blood from the body to the right atrium • Formed by the convergence of the illiac veins • Retroperitoneal • Right of the aorta • Normal size 1.5-2.5 cm • During expiration, • In a spontaneously breathing patient, • Just distal the hepatic vein • Varies with respiration
- 6. Physiology
- 7. Respiratory Variation “Due to changing intra-thoracic pressures” • Expands with expiration • Narrows with inspiration “The opposite in MV patients”
- 10. CAVAL INDEX (CI) CI = Minimal diameter Maximal diameter Maximum diameter X 100 (%)
- 11. CAVAL INDEX (IVCI) Volume Depletion Volume Overload 0% 100% IVCI >18% (ventilated)IVCI <10% (ventilated)
- 12. Main Idea
- 13. Main Idea • Change of IVC diameter > 50% = possible hypovolemia. • Change of < 20% indicates = will probably not respond to fluid challenge. • IVCD < 0.9 cm (spont. breathing), < 1.2 (ventilated) = Hypovolemia (COP likely to increase after Fluid Challenge). • IVCD > 2 cm = Euvol./Hypervolemia (No response to Fluid Challenge).
- 14. IVC vs. CVP Guidelines
- 15. IVC vs. CVP Guidelines
- 17. PROCEDURE
- 18. Positioning • Supine • Degree of head elevation has not been shown to make a significant difference in measurements
- 19. Probe Selection • Low frequency (2-5 MHz) • Curvi-linear (Abdominal), or Phased array (Cardiac)
- 22. • Most common approach • Place probe longitudinally just below the xiphoid process with the probe marker to the patient’s head (Curvi-linear Probe) • Look for IVC going into right atrium – may need to move probe 1-2cm to patient’s right and then tilt it slightly towards the heart Xiphoid View
- 23. Xiphoid View
- 24. Xiphoid View
- 25. Xiphoid View
- 26. IVC Longitudinal
- 27. IVC Longitudinal
- 29. Anterior Mid-Axillary View • Place probe longitudinally in right anterior mid- axillary line with marker towards the head • Look for IVC running longitudinally adjacent to liver crossing the diaphragm. • Track superiorly until it enters right atrium confirming that it is the IVC and not the aorta. • Similar to Morrison’s pouch view in FAST exam?!
- 34. Measuring the IVC Diameter 2 cm distal to right atrium or just distal to the hepatic vein
- 42. Pearls & Pitfalls Bowel Gas 1 May impede visualization in the xiphoid view 2 Gentle graded pressure may help move bowel out of way 3 Don’t press too hard or will collapse IVC causing false measurements 4 Consider anterior mid-axillary view
- 43. Plethoric (dilated) IVC • Volume overload. • Obstructive Shock: • Cardiac tamponade • Tension Pneumothorax. • Massive PE. Pearls & Pitfalls
- 44. Plethoric (dilated) IVC • Mitral regurgitation • Aortic stenosis • Status Asthmaticus • Right Heart Failure. Pearls & Pitfalls
- 45. Mechanical Ventilation Causes reversal of IVC changes with respiration “Maximum diameter with inspiration, minimum diameter with expiration” Pearls & Pitfalls
- 46. (False) Collapse of IVC • Diaphragmatic breathing (Kimura 2011) “Important in the ICU” • Raised intra-abdominal pressure (in animal studies: Takata 1990) • Even pressure from the probe! (anecdotally) Pearls & Pitfalls
- 47. Aorta Thick, echogenic walls Pulsatile High flow velocity Non-compressible No respiratory variation Above vertebral bodies IVC Thin walled Usually not pulsatile Low flow velocity Compressible Respiratory variation To the right of vertebral bodies IVC vs. Aorta Pearls & Pitfalls
- 49. IVC vs. Aorta
- 51. Take Home Message Shock + flat collapsing IVC = give fluid. <0.9cm (spontaneous breathing) <1.2cm IVCD, CI >18% (ventilated)
- 52. Shock + distended IVC = don’t give fluid. >2.5cm, IVCCI <10% (ventilated) Take Home Message
- 53. Serial IVC measurements seem useful! Take Home Message
- 54. IVC probably does help at extremes (Fat & Full Vs. Flat & Collapsing). Take Home Message
- 56. Mobile Apps
- 57. EGLS
- 59. SonoAccess
- 62. PHILIPS US Education App
- 63. Not the US result! Remember Treat the Patient
- 66. “The value of experience is not in seeing much, but in seeing wisely” William Osler
- 67. References • ACEP Policy Statement on Emergency Ultrasound Guidelines. Ann. Emerg. Med. 2009;53:550-70 • De Lorenzo RA, Morris MJ, William JB, et al. Does a simple bedside sonographic measurement of the inferior vena cava correlate to central venous pressure? J. Emer. Med. 2011; 42(4); 429-436. • Kosiak W, Swieton D, Piskunowicz M. Sonographic inferior vena cava/aorta diameter index, a new approach to the body fluid status assessment in children and young adults in emergency ultrasound preliminary study. Acad. J. Emerg. Med. 2008;26:320-5 • Nagdev AD, Merchant RC, Tirado-Gonzalez A, et al. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venouspressure. Ann.Emerg.Med. 2010;55:290-5. • Feissel M, Michard F, Faller JP, et al. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Med. 2004;30:1834-7. • Fields JM, Lee PA, Jenq KY, et al. The interrater reliability of inferior vena cava ultrasound by bedside clinician sonographers in emergency department patients. Acad. Emerg. Med. 2011;18:98- 101. • Kircher BJ, Himelman RB, Schiller NB. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J. Cardiol. 1990;66:493-6. • Emcrit.org.
- 69. “Patch Adams”
- 70. Thank You