Comparison between respiratory changes in the inferior vena cava diameter and pulse pressure variation to predict fluid responsiveness in postoperative patients

doi:10.1016/j.jcrc.2016.03.017

Journal of Critical Care

Volume 34, August 2016, Pages 46-49

https://doi.org/10.1016/j.jcrc.2016.03.017 Get rights and content

Abstract

Purpose

The objective of our study was to assess the reliability of the distensibility index of the inferior vena cava (dIVC) as a predictor of fluid responsiveness in postoperative, mechanically ventilated patients and compare its accuracy with that of the pulse pressure variation (PPV) measurement.

Materials and methods

We included postoperative mechanically ventilated and sedated patients who underwent volume expansion with 500 mL of crystalloids over 15 minutes. A response to fluid infusion was defined as a 15% increase in the left ventricular outflow tract velocity time integral according to transthoracic echocardiography. The inferior vena cava diameters were recorded by a subcostal view using the M-mode and the PPV by automatic calculation. The receiver operating characteristic (ROC) curves were generated for the baseline dIVC and PPV.

Results

Twenty patients were included. The area under the ROC curve for dIVC was 0.84 (95% confidence interval, 0.63-1.0), and the best cutoff value was 16% (sensitivity, 67%; specificity, 100%). The area under the ROC curve for PPV was 0.92 (95% confidence interval, 0.76-1.0), and the best cutoff was 12.4% (sensitivity, 89%; specificity, 100%). A noninferiority test showed that dIVC cannot replace PPV to predict fluid responsiveness (P = .28).

Conclusion

The individual PPV discriminative properties for predicting fluid responsiveness in postoperative patients seemed superior to those of dIVC.

Introduction

The early recognition and treatment of tissue hypoperfusion in the perioperative period are essential for preventing complications [1], [2], [3], [4]. The first-line intervention for the restoration of tissue perfusion is intravascular fluid administration [5]. Ideally, volume expansion should only be indicated for patients in whom the cardiac output is expected to increase. The correct identification of who would benefit from fluid administration allows for hemodynamic optimization and avoids ineffective, or even deleterious, volume expansion [6]. Fluid overload in surgical patients has been associated with increased complications [7], [8], [9], [10].

Perioperative patients are usually sedated and under controlled mechanical ventilation. In these conditions, the pulse pressure variation (PPV) is recognized as an accurate predictor of fluid responsiveness [11], [12]. Several other minimally invasive methods have been used to determine whether a patient is fluid responsive, including transthoracic echocardiography [13], [14]. The changes in the inferior vena cava (IVC) diameter during mechanical ventilation were previously described as a reliable, noninvasive predictor of fluid responsiveness in septic patients [15], [16]. However, the accuracy of the distensibility index of the inferior vena cava (dIVC) has been challenged in some recent studies [17], [18].

The objective of our study was to assess the reliability of dIVC as a predictor of fluid responsiveness in postoperative, mechanically ventilated patients and then compare it with simultaneous PPV recording.

Section snippets

Materials and methods

This study was performed in a 35-bed mixed intensive care unit (ICU) at a Brazilian teaching hospital. The local ethical and research committee (Federal University of São Paulo) approved the protocol under the number 186.785, and written informed consent was obtained from all patients or their relatives.

Results

From February 2013 to September 2014, 30 patients were eligible for our study, and 20 of these were included. We excluded 3 patients because of poor acoustic windows, and 1 patient submitted to surgery around the IVC. The other reasons for exclusion were changes in vasoactive drugs (n = 3), arrhythmia (n = 2), and declined consent (n = 1). Most patients (65%) were admitted to ICU after neurosurgical procedures because this type of surgery very often requires sedation in the immediate postoperative

Discussion

In this study, we were able to show that the individual PPV discriminative properties for predicting fluid responsiveness in postoperative patients seemed superior to those of dIVC.

The rationale for volume expansion is to increase venous return to increase cardiac output through the Frank-Starling mechanism [23]. However, only half of all hemodynamically unstable patients are preload responsive [24]. In this context, several studies have clearly shown that neither pressure nor volume markers of

Conclusion

In sedated postoperative patients under mechanical ventilation with tidal volume of 8 mL/kg predicted body weight, the individual PPV discriminative properties for predicting fluid responsiveness seemed superior to those of dIVC. As our study was performed in a controlled environment in a select group of patients, the results may not be generalizable to all ICU patients.

Acknowledgments

The authors would like to thank Samsung Medison Brazil for supplying the echocardiogram.

References (39)

M.P. Grocott et al.
Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane systematic review
Br J Anaesth
(2013)
V. Mohsenin
Assessment of preload and fluid responsiveness in intensive care unit. How good are we?
J Crit Care
(2015)
R.M. Stewart et al.
Less is more: improved outcomes in surgical patients with conservative fluid administration and central venous catheter monitoring
J Am Coll Surg
(2009)
G.A. Schmidt et al.
Shock: ultrasound to guide diagnosis and therapy
Chest
(2012)
D. Sobczyk et al.
Bedside ultrasonographic measurement of the inferior vena cava fails to predict fluid responsiveness in the first 6 hours after cardiac surgery: a prospective case series observational study
J Cardiothorac Vasc Anesth
(2015)
F. Jardin et al.
Echocardiographic pattern of acute cor pulmonale
Chest
(1997)
P.H. Mayo et al.
American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography
Chest
(2009)
F.G. Freitas et al.
Predictive value of pulse pressure variation for fluid responsiveness in septic patients using lung-protective ventilation strategies
Br J Anaesth
(2013)
F. Michard et al.
Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence
Chest
(2002)
L. Guerin et al.
Monitoring volume and fluid responsiveness: from static to dynamic indicators
Best Pract Res Clin Anaesthesiol
(2013)

J.A. Romand et al.

Cardiopulmonary effects of positive pressure ventilation during acute lung injury

Chest

(1995)

S. Nakao et al.

Effects of positional changes on inferior vena caval size and dynamics and correlations with right-sided cardiac pressure

Am J Cardiol

(1987)

W.C. Shoemaker et al.

Clinical trial of an algorithm for outcome prediction in acute circulatory failure

Crit Care Med

(1982)

W.C. Shoemaker et al.

Clinical trial of survivors' cardiorespiratory patterns as therapeutic goals in critically ill postoperative patients

Crit Care Med

(1982)

A. Meregalli et al.

Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients

Crit Care

(2004)

P.E. Marik et al.

Hemodynamic parameters to guide fluid therapy

Ann Intensive Care

(2011)

B. Brandstrup et al.

Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial

Ann Surg

(2003)

N.N. Rahbari et al.

Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery

Br J Surg

(2009)

S.M. Lobo et al.

Restrictive strategy of intraoperative fluid maintenance during optimization of oxygen delivery decreases major complications after high-risk surgery

Crit Care

(2011)

Cited by (30)

Comparison of vena cava distensibility index and pulse pressure variation for the evaluation of intravascular volume in critically ill children
2022, Jornal de Pediatria
Citation Excerpt :
DeBacker et al. showed that PPV may not be sufficient for determining fluid responsiveness in the presence of arrhythmia or spontaneous respiration, or in cases where the tidal volume is < 8 mL/kg or the heart rate/respiratory rate is < 3.6.23,24 A small number of adult studies evaluated the effectiveness of dIVC and PPV for assessing intravascular volume.25-27 In the present study, initially, there was a strong negative correlation between CVP and PPV, similar to the results for dIVC.
In this study, the authors aimed to evaluate the effectiveness of the vena cava distensibility index and pulse pressure variation as dynamic parameters for estimating intravascular volume in critically ill children.
Patients aged 1 month to 18 years, who were hospitalized in the present study's pediatric intensive care unit, were included in the study. The patients were divided into two groups according to central venous pressure: hypovolemic (< 8 mmHg) and non-hypovolemic (central venous pressure ≥ 8 mmHg) groups. In both groups, vena cava distensibility index was measured using bedside ultrasound and pulse pressure variation. Measurements were recorded and evaluated under arterial monitoring.
In total, 19 (47.5%) of the 40 subjects included in the study were assigned to the central venous pressure ≥ 8 mmHg group, and 21 (52.5%) to the central venous pressure < 8 mmHg group. A moderate positive correlation was found between pulse pressure variation and vena cava distensibility index (r = 0.475, p < 0.01), while there were strong negative correlations of central venous pressure with pulse pressure variation and vena cava distensibility index (r = –0.628, p < 0.001 and r = –0.760, p < 0.001, respectively). In terms of predicting hypovolemia, the predictive power for vena cava distensibility index was > 16% (sensitivity, 90.5%; specificity, 94.7%) and that for pulse pressure variation was > 14% (sensitivity, 71.4%; specificity, 89.5%).
Vena cava distensibility index has higher sensitivity and specificity than pulse pressure variation for estimating intravascular volume, along with the advantage of non-invasive bedside application.
Respiratory variability of inferior vena cava at different mechanical ventilator settings
2021, American Journal of Emergency Medicine
Citation Excerpt :
In a recent study, de Oliveira et al. assessed the reliability of IVC DI in a similar patient sample mechanically ventilated on volume-controlled mode with a TV of 8 ml/kg and defined a 15% increase in LVOT VTI as fluid responsiveness. They found the AUC for IVC DI as 84%, sensitivity as 67%, and specificity as 100% at their calculated cut-off value of 16% [26]. In a similar study, Moretti and Pizzi evaluated ΔIVC, accepted 15% increase of cardiac index as the criterion, and reported a sensitivity of 71% and specificity of 100%.
Assessment of the respiratory changes of the inferior vena cava (IVC) diameter have been investigated as a reliable tool to estimate the volume status in mechanically ventilated and spontaneously breathing patients. Our purpose was to compare the echocardiographic measurements the IVC diameter, stroke volume and cardiac output in different positive pressure ventilation parameters.
This prospective clinical study with crossover design was conducted in the Intensive Care Unit (ICU). Twenty-five sedated, paralyzed, intubated, and mechanically ventilated patients with volume control mode (CMV) in the ICU due to respiratory failure were included in the study. Positive End-Expiratory Pressure (PEEP) and Tidal Volume (TV) were changed in each patient consecutively (Group A: TV 6 ml/kg, PEEP 5 cmH20, B: TV 6, PEEP 8, C: TV 8, PEEP 5, D: TV 8, PEEP 8) and the changes in vital parameters, central venous pressure (CVP) and ultrasonographic changes in IVC and cardiac parameters were measured. All measures were compared between groups by robust repeated measures ANOVA with trimmed mean.
The respiratory changes of the IVC diameter and echocardiographic parameters showed no significant difference in separate mechanical ventilator settings. Significant difference was found in peak and plateau pressure values among groups (p < 0.05).
The results of our study suggest that IVC related parameters are not affected with different ventilatory settings. Further studies are needed to confirm the reliability of these parameters as a predictor of fluid assessment.
Comparative Analysis of the Collapsibility Index and Distensibility Index of the Inferior Vena Cava Through Echocardiography with Pulse Pressure Variation That Predicts Fluid Responsiveness in Surgical Patients: An Observational Controlled Trial
2020, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
This was the cutoff value to assess the accuracy of ultrasound measurements of the IVC diameter. According to previous studies,14,16 the required sample size was 20, considering a minimum agreement of 70% between the icIVC and the idIVC and PPV, with a type I error of 5% and sample power of 95%. Parametric continuous data are expressed as mean and standard deviation, and nonparametric data are expressed as median and interquartile range.
The objective for the present study was to compare the collapsibility (IcIVC) and distensibility (IdIVC) indices of the inferior vena cava with pulse pressure variation (PPV) and determine the accuracy and cutoff points of IcIVC and IdIVC that best predict response to intravenous fluid therapy in surgical patients.
Observational, prospective, nonblinded, single center.
Hospital do Servidor Público Estadual de São Paulo, in São Paulo, Brazil.
Volunteer surgical patients.
This prospective study evaluated adult surgical patients before and after they underwent mechanical ventilation. IcIVC and IdIVC measurements were obtained with echocardiography and PPV through arterial catheterization.
Twenty-two patients with a mean age of 55.7 ± 10.9 years were included; 31.8% of the study participants had PPV values >13% and were shown to be responsive to fluid. A good correlation was detected between PPV and icIVC (R² = 0.71; p < 0.001) and between PPV and idIVC (R² = 0.79; p < 0.001). The area under the receiver operating characteristic curve was 0.98 for icIVC (95% confidence interval 0.81-0.99; p < 0.001) and 0.88 for idIVC (95% confidence interval 0.67-0.98; p < 0.001).
PPV was found to have good correlation with the inferior vena cava diameter variation using echocardiography in surgical patients undergoing spontaneous and artificial ventilation. The cutoff values that best predicted PPV >13% were >40% for icIVC and >17.6% for idIVC.
Respiratory variation in aortic blood peak velocity and caudal vena cava diameter can predict fluid responsiveness in anaesthetised and mechanically ventilated dogs
2017, Veterinary Journal
Citation Excerpt :
We measured VTI as a surrogate for SV, both before and after volume expansion. In several studies in humans, VTI has been used as a SV surrogate to measure the variation of left ventricular ejection in the same subject (Pereira de Souza Neto et al., 2011; Brun et al., 2013; de Oliveira et al., 2016). This approach to monitor cardiovascular function has several advantages both in clinical and experimental settings in veterinary medicine.
Dynamic preload indices, such as systolic pressure variation (SPV), aortic flow peak velocity variation (ΔVpeak) and distensibility index of the caudal vena cava (CVCDI), are reliable indices for predicting fluid responsiveness in humans. This study aimed to investigate the ability of these indices to predict fluid response in 24 healthy dogs undergoing general anaesthesia and mechanical ventilation. Aortic flow peak velocity variation (∆Vpeak), CVCDI, and SPV were calculated before volume expansion (5 mL/kg bolus of lactated Ringer’s solution). The aortic velocity time integral (VTI) was measured before and after volume expansion as a surrogate of stroke volume. Dogs were considered responders (n = 9) when the VTI increase was ≥15% and non-responders (n = 15) when the increase was <15%.
Before volume expansion, ΔVpeak, CVCDI and SPV were higher in responders than in non-responders (P = 0.0009, P = 0.0003, and P = 0.0271, respectively). Receiver operating characteristic (ROC) curves were plotted for the three indices. The areas under the ROC curves for SPV, ΔVpeak, and CVCDI were 0.91 (CI 0.73–0.99; P = 0.0001), 0.95 (CI 0.77–1; P = 0.0001), and 0.78 (CI 0.56–0.92; P = 0.015), respectively. The best cut-offs were 6.7% for SPV (sensitivity, 77.78%; specificity, 93.33%), 9.4% for ΔVpeak (sensitivity, 88.89%; specificity, 100%), and 24% for CVCDI (sensitivity, 77.78%; specificity, 73.33). In conclusion, ΔVpeak, CVCDI, and SPV are reliable predictors of fluid responsiveness in healthy dogs undergoing general anaesthesia and mechanical ventilation.
Correlation Between Transhepatic and Subcostal Inferior Vena Cava Views to Assess Inferior Vena Cava Variation: A Pilot Study
2017, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
The inter-rater reliability for assessment of IVC DV was almost perfect, with an ICC of 0.96 (CI, 0.80-0.99) for the SC view, and ICC of 0.93 (CI, 0.81-0.98) for the TH view. Despite its limitations in the immediate postoperative period,10,35,36 IVC variation remains a noninvasive, simple, and validated index of volume status to predict fluid responsiveness in spontaneously breathing and mechanically ventilated patients. In the perioperative care of patients undergoing cardiac surgery, transesophageal echocardiography (TEE) has been the modality of choice for the assessment of cardiac function and prediction of fluid responsiveness in the operating room and immediate postoperative period.
To assess the feasibility and reliability of transthoracic echocardiography to measure inferior vena cava (IVC) diameter variation using a transhepatic view.
Prospective cohort study.
Single-center hospital.
Forty consecutive patients undergoing elective cardiac surgery.
Bedside transthoracic echocardiography.
Correlation between the two views was measured using Pearson R, while agreement was measured using the intraclass correlation coefficient (ICC). In a nested sub-study of 16 randomly selected participants, all images were re-rated by the same rater, who was blinded to the original measurement results, and by a second blinded operator. Correlation between the subcostal and transhepatic views was moderate when assessing maximum (R 0.46; 95% confidence interval [CI], 0.18-0.68), and minimum (R 0.55; CI, 0.29-0.74) IVC diameter. Correlation when measuring IVC diameter variation was higher (R 0.70; CI, 0.49-0.83). Agreement between the two views for IVC diameter variation measurement was substantial (ICC 0.73; CI, 0.49-0.85). Intra-rater reliability was excellent (ICC 0.95-0.99).
Agreement between subcostal and transhepatic views was substantial for the assessment of IVC diameter variation; however, the magnitude of agreement was less than anticipated. Further research is needed to determine if the transhepatic view can be used reliably in the assessment of fluid responsiveness.
Does respiratory variation in inferior vena cava diameter predict fluid responsiveness in adult patients? A systematic review and meta-analysis of diagnostic accuracy studies
2023, Hong Kong Journal of Emergency Medicine

View all citing articles on Scopus

View full text

Clinical PotpourriComparison between respiratory changes in the inferior vena cava diameter and pulse pressure variation to predict fluid responsiveness in postoperative patients

Abstract

Purpose

Materials and methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Acknowledgments

Br J Anaesth

J Crit Care

J Am Coll Surg

Chest

J Cardiothorac Vasc Anesth

Chest

Chest

Br J Anaesth

Chest

Best Pract Res Clin Anaesthesiol

Chest

Am J Cardiol

Clinical trial of an algorithm for outcome prediction in acute circulatory failure

Crit Care Med

Clinical trial of survivors' cardiorespiratory patterns as therapeutic goals in critically ill postoperative patients

Crit Care Med

Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients

Crit Care

Hemodynamic parameters to guide fluid therapy

Ann Intensive Care

Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial

Ann Surg

Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery

Br J Surg

Restrictive strategy of intraoperative fluid maintenance during optimization of oxygen delivery decreases major complications after high-risk surgery

Crit Care

Clinical Potpourri
Comparison between respiratory changes in the inferior vena cava diameter and pulse pressure variation to predict fluid responsiveness in postoperative patients