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    Intensivist Use of Hand-Carried Ultrasonography To Measure IVC Collapsibility in Estimating Intravascular Volume Status: Correlations With CVP

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    Arjun Rajagopalan
    Measurements of IVC-CI (inferior vena cava compressibility index) by INBU (intensivist performed bedside ultrasound)can provide a useful guide to noninvasive volume status assessment in SICU patients. ... Additional studies are needed to confirm and expand on findings of this study.

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    Intensivist Use of Hand-Carried Ultrasonography To Measure IVC Collapsibility in Estimating Intravascular Volume Status: Correlations With CVP

    Uploaded by

    Arjun Rajagopalan
    658 views2 pages
    Measurements of IVC-CI (inferior vena cava compressibility index) by INBU (intensivist performed bedside ultrasound)can provide a useful guide to noninvasive volume status assessment in SICU patients. ... Additional studies are needed to confirm and expand on findings of this study.

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    Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in estimating intravascular volume status: correlations with CVP

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    Measurements of IVC-CI (inferior vena cava compressibility index) by INBU (intensivist performed bedside ultrasound)can provide a useful guide to noninvasive volume status assessment in SICU patients. ... Additional studies are needed to confirm and expand on findings of this study.

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    Intensivist Use of Hand-Carried Ultrasonography To Measure IVC Collapsibility in Estimating Intravascular Volume Status: Correlations With CVP

    Uploaded by

    Arjun Rajagopalan
    Measurements of IVC-CI (inferior vena cava compressibility index) by INBU (intensivist performed bedside ultrasound)can provide a useful guide to noninvasive volume status assessment in SICU patients. ... Additional studies are needed to confirm and expand on findings of this study.

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    Dissections DIAGNOSIS

    19 August 2009
    Evidence-based Medicine for Surgeons

    Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in estimating


    intravascular volume status: correlations with CVP
    Authors: Stawicki SP, Braslow BM, Panebianco NL, et al
    Journal: J American College of Surgeons 2009; 209: 55–61
    Centre: University of Pennsylvania School of Medicine, Philadelphia, PA, USA
    Clinical examination is known to be unreliable in the evaluation of intravascular volume, leading
    to the need for more objective means of assessment. Recent technological advances have made
    ultrasonography equipment compact, mobile, easy to use, and inexpensive. Clinician-performed
    bedside ultrasonography examinations have become popular methods of round-the-clock, rapidly
    BACKGROUND deployed strategies for initial assessment and guide to subsequent therapy in a wide range of
    acute clinical situations. Intensivist-performed bedside ultrasonography (INBU) has been used in
    evaluation of the circulating volume status in critically ill patients. One widely used parameter in
    IVC assessment of intravascular volume is the IVC collapsibility index (IVC-CI).

    RESEARCH QUESTION IN SUMMARY


    Population IVC collapsibility index (IVC - CI) versus CVP

    Adult patients admitted to a high- Number Mean CVP (mm Hg)


    acuity, surgical intensive care unit.
    IVC-CI group
    Indicator variable High (> 0.6) 13 7.40
    IVC collapsibility index (IVC-CI) Intermediate (0.2 - 0.6) 41 9.75
    measured by intensivist-performed
    bedside ultrasonography (INBU) Low (< 0.2) 29 12.0
    using a hand-carried An IVC-CI in the intermediate range (0.20 - 0.60) was not helpful in
    ultrasonography unit. discriminating CVP

    Outcome variable
    Authors' claim(s): “...Measurements of IVC-CI by INBU can provide a
    Primary: circulating volume status useful guide to noninvasive volume status assessment in SICU patients. ...
    Additional studies are needed to confirm and expand on findings of this
    Comparison study.”
    CVP measurement.

    THE TISSUE REPORT


    Let's first set aside the flaws in this study; there
    IVC-CI consists of the difference between the end-expiratory (IVCD-
    are many and are easily spotted. The authors exp) and end-inspiratory IVC diameter (IVCD-insp) divided by IVCD-
    are quick to state that "large-scale prospective exp. IVC diameter measurement is obtained using M-mode
    studies will be needed to confirm and expand ultrasonography. Studies have shown an inverse relationship
    on the findings of the present study". This between IVC-CI and right atrial (RA) pressure or CVP, where higher
    study enlarges the growing list of physician- IVC-CI values correlate with low RA filling pressures (low CVP) and
    performed, bedside ultrasound assessments lower IVC-CI values correlate with higher RA filling pressures.
    that add value to the process of decision For eg. if IVCD-exp = 18.3 mm and IVCD-insp = 3.8mm, the IVC-CI
    making in acute situations. Future reports on would be (18.3 - 3.8)/18.3, or 0.792.
    this matter will clarify the value of this study.

    EBM-O-METER
    Evidence level Overall rating Bias levels
    Double blind RCT Sampling
    Randomized controlled trial (RCT) Comparison
    Trash Swiss Safe News-
    Prospective cohort study - not randomized cheese worthy Measurement
    Life's too Holds water
    short for this Full of holes “Just do it”
    Case controlled study
    Interestingl | Novel l | Feasible l
    Case series - retrospective  Ethical l | Resource saving l

    The devil is in the details (more on the paper) ... 

    © Dr Arjun Rajagopalan
    SAMPLING
    Sample type Inclusion criteria Exclusion criteria Final score card
    Simple random Adult (older than Not stated IVC-CI vs CVP study
    18) patients
    Stratified random Target ?
    admitted to an SICU
    Cluster who had a CVP Accessible 124
    catheter placed 
    Consecutive Intended 101
    Convenience Drop outs 18
    Judgmental Study 83

     = Reasonable | ? = Arguable |  = Questionable


    Duration of the study: October 2006 and April 2007

    Sampling bias: The drop off between accessible patients and the study group is very large. This is a single centre
    experience.

    COMPARISON
    Randomized Case-control Non-random Historical None

    Controls - details
    Allocation details The INBU-derived measurements of IVC-CI were compared with invasively measured CVP.
    After completion of the ultrasonography examination, members of the SICU team caring for
    the patient, blinded to ultrasonography findings, provided data on a standardized form about
    patient demographics, vital signs, and invasive hemodynamic monitoring variables obtained at
    the time of the examination.
    Comparability -
    Disparity -

    Comparison bias: -

    MEASUREMENT
    Measurement error
    Device used Device error Observer error
    Gold std.

    Device suited to task


    Training

    Scoring

    Blinding
    Repetition

    Protocols

    Y ? N

    1.IVC-CI by INBU ? N ? Y Y N Y

    All intensivists had earlier ultrasonography experience in general bedside sonography (including focused assessment
    with sonography for trauma, gallbladder, aorta, and first-trimester pregnancy evaluations) and an additional 3 hours of
    didactic review of the techniques of acquisition and interpretation of sonographic images of the heart and IVC.
    A record of each examination was stored in the form of static images and 6-second digital video clips. Sonographers
    recorded their interpretation of each examination and completion times on a standardized form blinded to the results of
    all invasive and noninvasive monitoring data.
    IVC-CI was defined in one of two ways, depending on whether or not the patient was intubated.
    IVC-CI measurements were grouped by range (<.20, 0.20 to 0.60, and >0.60). CVP values were also grouped into
    three ranges: <7 mmHg, 7 to 12 mmHg, and >12 mmHg.

    Measurement bias: There was no attempt to measure observer variability: a critical element of bias in these
    studies. The grouping of CVP by three ranges is arbitrary. CVP is well known to have no standardizable normal
    ranges.

    © Dr Arjun Rajagopalan

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