Ivc guided fluid management in the icu
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The document provides information on using ultrasound-guided inferior vena cava (IVC) measurements to guide fluid management in intensive care unit (ICU) patients. It discusses the anatomy and physiology of the IVC, how respiratory variations in IVC diameter can indicate fluid status, and guidelines for IVC measurements and interpretations. The main idea is that a change in IVC diameter greater than 50% may indicate possible hypovolemia, while a change of less than 20% likely won't respond to fluid challenges. The document provides guidance on performing the procedure, potential pitfalls, and takeaways on using IVC measurements at extremes to guide fluid resuscitation in shock patients.
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