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Mesin L, Giovinazzo T, D'Alessandro S, Roatta S, Raviolo A, Chiacchiarini F, Porta M, Pasquero P. Improved Repeatability of the Estimation of Pulsatility of Inferior Vena Cava. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:2830-2843. [PMID: 31303402 DOI: 10.1016/j.ultrasmedbio.2019.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/03/2019] [Accepted: 06/03/2019] [Indexed: 06/10/2023]
Abstract
The inferior vena cava (IVC) shows variations of cross section over time (pulsatility) induced by different stimulations (e.g., breathing and heartbeats). Pulsatility is affected by patients' volume status and can be investigated by ultrasound (US) measurements. An index of IVC pulsatility based on US visualization and called caval index (CI) was proposed as a non-invasive indirect measurement of the volume status. However, its estimation is not standardized, operator dependent and affected by movements of the vein and non-uniform pulsatility. We introduced a software that processes B-mode US video clips to track IVC movements and estimate CI on an entire portion of the vein. This method is here compared to the standard approach in terms of repeatability of the estimated CI, reporting on the variability over different respiratory cycles, longitudinal IVC sections and intra-/inter-observers. Our method allows to reduce the variability of CI assessment, making a step toward its standardization.
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Affiliation(s)
- Luca Mesin
- Mathematical Biology and Physiology, Department of Electronics and Telecommunications, Politecnico di Torino, Torino, Italy.
| | - Tatiana Giovinazzo
- Mathematical Biology and Physiology, Department of Electronics and Telecommunications, Politecnico di Torino, Torino, Italy
| | - Simone D'Alessandro
- Mathematical Biology and Physiology, Department of Electronics and Telecommunications, Politecnico di Torino, Torino, Italy
| | - Silvestro Roatta
- Integrative Physiology Lab, Department of Neuroscience, University of Torino, Torino, Italy
| | | | | | - Massimo Porta
- Department of Medical Sciences, University of Torino, Torino, Italy
| | - Paolo Pasquero
- Department of Medical Sciences, University of Torino, Torino, Italy
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Mesin L, Pasquero P, Roatta S. Tracking and Monitoring Pulsatility of a Portion of Inferior Vena Cava from Ultrasound Imaging in Long Axis. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:1338-1343. [PMID: 30739722 DOI: 10.1016/j.ultrasmedbio.2018.10.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/09/2018] [Accepted: 10/22/2018] [Indexed: 06/09/2023]
Abstract
Pulsatility of the inferior vena cava (IVC) provides information on volume status in healthy subjects and in many clinical conditions. The ultrasound (US) approach to estimating the caval index (CI) is not standardized, as it is operator dependent and vulnerable to measurement errors because of different factors, including movements of the IVC and non-uniform IVC pulsatility along its longitudinal axis. We propose and test in healthy subjects an innovative automated approach, which tracks the IVC movements registered in a B-mode US video clip and estimates the pulsatility of an entire portion of the vein rather than of a single arbitrary section. Large variations in CI estimates were observed along the longitudinal axis (in the worst case, CI ranged between 15% and 60%), indicating the importance of investigating a whole portion of the vessel.
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Affiliation(s)
- Luca Mesin
- Mathematical Biology and Physiology, Department of Electronics and Telecommunications, Politecnico di Torino, Torino, Italy.
| | - Paolo Pasquero
- Department of Medical Sciences, University of Torino, Torino, Italy
| | - Silvestro Roatta
- Integrative Physiology Lab, Department of Neuroscience, University of Torino, Torino, Italy
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McGregor D, Sharma S, Gupta S, Ahmad S, Godec T, Harris T. Emergency department non-invasive cardiac output study (EDNICO): a feasibility and repeatability study. Scand J Trauma Resusc Emerg Med 2019; 27:30. [PMID: 30867006 PMCID: PMC6417111 DOI: 10.1186/s13049-019-0586-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 01/04/2019] [Indexed: 12/27/2022] Open
Abstract
Background There is little published data investigating non-invasive cardiac output monitoring in the emergency department (ED). We assessed six non-invasive fluid responsiveness monitoring methods which measure cardiac output directly or indirectly for their feasibility and repeatability of measurements in the ED: (1) left ventricular outflow tract echocardiography derived velocity time integral, (2) common carotid artery blood flow, (3) suprasternal aortic Doppler, (4) bioreactance, (5) plethysmography with digital vascular unloading method, and (6) inferior vena cava collapsibility index. Methods This is a prospective observational study of non-invasive methods of assessing fluid responsiveness in the ED. Participants were non-ventilated ED adult patients requiring intravenous fluid resuscitation. Feasibility of each method was determined by the proportion of clinically interpretable measurements from the number of measurement attempts. Repeatability was determined by comparing the mean difference of two paired measurements in a fluid steady state (after participants received an intravenous fluid bolus). Results 76 patients were recruited in the study. A total of 207 fluid responsiveness measurement sets were analysed. Feasibility rates were 97.6% for bioreactance, 91.3% for vascular unloading method with plethysmography, 87.4% for common carotid artery blood flow, 84.1% for inferior vena cava collapsibility index, 78.7% for LVOT VTI, and 76.8% for suprasternal aortic Doppler. The feasibility rates difference between bioreactance and all other methods was statistically significant. Conclusion Our study shows that non-invasive fluid responsiveness monitoring in the emergency department may be feasible with selected methods. Higher repeatability of measurements were observed in non-ultrasound methods. These findings have implications for further studies specifically assessing the accuracy of such non-invasive cardiac output methods and their effect on patient outcome in the ED in fluid depleted states such as sepsis. Electronic supplementary material The online version of this article (10.1186/s13049-019-0586-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- D McGregor
- Queen Mary University London and Barts Health NHS Trust, London, UK.
| | - S Sharma
- University of Western Australia School of Medicine and Pharmacology, Perth, Australia
| | - S Gupta
- University of Western Australia School of Medicine and Pharmacology, Perth, Australia
| | - S Ahmad
- Emergency Department Research Group, Royal London Hospital, London, UK
| | - T Godec
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Tim Harris
- Emergency Medicine, Queen Mary University London and Barts Health NHS Trust, London, UK
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Whitford R, Powell EK, Tilney PVR. A 70 Year-Old Woman with Postoperative Hypotension. Air Med J 2018; 37:82-84. [PMID: 29478581 DOI: 10.1016/j.amj.2017.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 11/07/2017] [Indexed: 06/08/2023]
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Dynamic Limb Bioimpedance and Inferior Vena Cava Ultrasound in Patients Undergoing Hemodialysis. ASAIO J 2017; 62:463-9. [PMID: 26919184 DOI: 10.1097/mat.0000000000000355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Assessment of volume status in critically ill patients poses a challenge to clinicians. Measuring changes in the inferior vena cava (IVC) diameter using ultrasound is becoming a standard tool to assess volume status. Ultrasound requires physicians with significant training and specialized expensive equipment. It would be of significant value to be able to obtain this measurement continuously without physician presence. We hypothesize that dynamic changes in limb's bioimpedance in response to respiration could be used to predict changes in IVC. Forty-six subjects were tested a hemodialysis session. Impedance was measured via electrodes placed on the arm. Simultaneously, the IVC diameter was assessed by ultrasound. Subjects were asked to breathe spontaneously and perform respiratory maneuvers using a respiratory training device. Impedance (dz) was determined and compared with change in IVC diameter (dIVC; r = 0.76, p < 0.0001). There was significant relationship between dz and dIVC (p< 0.0001). Receiver-operator curves for dz at thresholds of dIVC (20% to70%) demonstrated high predictive power with areas under the curves (0.87-0.99, p < 0.0001). This evaluation suggests that real-time dynamic changes in limb impedance are capable of tracking a wide range of dynamic dIVC. This technique might be a suitable surrogate for monitoring real-time changes in dIVC to assess intravascular volume status.
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Lucas BP, D’Addio A, Clark J, Block C, Manning H, Remillard B, Leiter JC. Reproducibility of point-of-care ultrasonography for central vein diameter measurement: Separating image acquisition from interpretation. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:488-496. [PMID: 28880382 PMCID: PMC5599119 DOI: 10.1002/jcu.22491] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 03/04/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE Central vein point-of-care ultrasonography must be reproducible to detect intravascular volume changes. We sought to determine which measurement step, image acquisition or interpretation, could be more compromising for reproducibility. METHODS Three investigators each acquired inferior vena cava (IVC) and internal jugular (IJV) vein ultrasonographic sequences (US) from a convenience sample of 21 hospitalized general medicine participants and then interpreted each US three separate times. We partitioned the random errors of acquisition and interpretation, attributing wider dispersions of each to larger reductions in reproducibility. RESULTS We analyzed 351 interpretations of 39 IVC and 432 interpretations of 48 IJV US. Reproducibility of the maximum (standard error of measurement 3.3 mm [95% confidence interval, CI 2.7-4.2 mm]) and minimum (4.8 mm [3.9-6.3 mm]) IVC diameter measurements were worse than that of the mediolateral (2.5 mm [2.0-3.2 mm]) and anteroposterior (2.5 mm [2.0-3.1 mm]) IJV diameters. The dispersions of random measurement errors were wider among acquisitions than interpretations. CONCLUSIONS Among our investigators, central vein diameter measurements obtained by point-of-care ultrasonography are not sufficiently reproducible to distinguish clinically meaningful intravascular volume changes from measurement errors. Reproducibility could be most effectively improved by reducing the random measurement errors of acquisition. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:488-496, 2017.
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Affiliation(s)
- Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | | | - Jennifer Clark
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Clay Block
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Harold Manning
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Brian Remillard
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - JC Leiter
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Pasquero P, Albani S, Sitia E, Taulaigo AV, Borio L, Berchialla P, Castagno F, Porta M. Inferior vena cava diameters and collapsibility index reveal early volume depletion in a blood donor model. Crit Ultrasound J 2015; 7:17. [PMID: 26537114 PMCID: PMC4633475 DOI: 10.1186/s13089-015-0034-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Changes of volume status can be readily inferred from variations in diameter of the inferior vena cava (IVC) measured by ultrasound. However the effect of IVC changes following acute blood loss are not fully established. In this study, three different approaches to measuring IVC variables were compared in healthy blood donors, as a model of acute volume depletion, in order to establish their relative ability to detect acute blood loss. METHODS Inspiratory and expiratory IVC diameters were measured before and after blood donation in hepatic long axis, hepatic short axis and renal short axis views using a 2-5 MHz curvilinear probe. All measurements were recorded and examined in real-time and post-processing sessions. RESULTS All windows performed satisfactorily but the renal window approach was feasible in only 30 out of 47 subjects. After blood donation, IVC diameters decreased in hepatic long axis, hepatic short axis and renal short axis (expiratory: -19.9, -18.0, -26.5 %; CI 95 %: 14.5-24.1; 13.1-22.9; 16.0-35.9, respectively) (inspiratory: -31.1, -31.6, -36.5 %; CI 95 %: 21.3-40.1; 18.8-45.2; 23.4-46.0, respectively), whereas the IVC collapsibility index increased by 21.6, 22.6 and 19.3 % (CI 95 %: 11.6-42.9; 18.5-39.5; 7.7-30.0). IVC diameters appeared to return to pre-donation values within 20 min but this was only detected by the hepatic long axis view. CONCLUSIONS IVC diameter and collapsibility index variations, as measured in M mode, consistently detect volume changes after blood donation. The longitudinal mid-hepatic approach performed better by allowing a panoramic view, avoiding anatomical aberrancies at fixed points and permitting to identify the best possible perpendicular plane to the IVC. In addition, it was able to detect time-dependent physiological volume replacement. In contrast, in our hands, the renal window could not be visualized consistently well.
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Affiliation(s)
- Paolo Pasquero
- Department of Medical Sciences, University of Turin, Corso AM Dogliotti 14, 10126, Turin, Italy.
| | - Stefano Albani
- Department of Medical Sciences, University of Turin, Corso AM Dogliotti 14, 10126, Turin, Italy.
| | - Elena Sitia
- Department of Medical Sciences, University of Turin, Corso AM Dogliotti 14, 10126, Turin, Italy.
| | - Anna Viola Taulaigo
- Department of Medical Sciences, University of Turin, Corso AM Dogliotti 14, 10126, Turin, Italy.
| | - Lorenzo Borio
- Department of Medical Sciences, University of Turin, Corso AM Dogliotti 14, 10126, Turin, Italy.
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.
| | - Franco Castagno
- Blood Bank, AOU Città della Salute e della Scienza, Turin, Italy.
| | - Massimo Porta
- Department of Medical Sciences, University of Turin, Corso AM Dogliotti 14, 10126, Turin, Italy.
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Gui J, Guo J, Nong F, Jiang D, Xu A, Yang F, Chen Q, Lin Y. Impact of individual characteristics on sonographic IVC diameter and the IVC diameter/aorta diameter index. Am J Emerg Med 2015; 33:1602-5. [PMID: 26306433 DOI: 10.1016/j.ajem.2015.06.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 06/14/2015] [Accepted: 06/19/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND The inferior vena cava (IVC) parameters, including its diameter and collapsibility index have been evaluated for fluid status for over 30 years, but little is known about the impacts of patient characteristics on IVC parameters. The purpose of this study was to explore the relationships between individual patient characteristics and IVC parameters in healthy Chinese adult volunteers. METHODS From February 2012 to May 2012, 216 healthy volunteers older than the age of 18 years were consecutively enrolled in our study. The individual characteristics and presence or absence of hypertension of each participant were recorded. Sonographic measurements of IVC and abdominal aorta diameter (Ao) were performed (DP-6900; Mindray, Shenzhen, China). RESULTS Volunteers ranged in age from 18 to 84 years (43.7 ± 7.8 years), and 50.5% were males. In univariate analyses, maximum IVC diameter (IVCmax) was negatively correlated with age (years) (r = -0.171, P = .012) and positively correlated with sex (men) (r = 0.174, P = .01), height (centimeters) (r = 0.281, P < .001), and body surface area (square meters) (r = 0.173, P = .011). The IVC/Ao index was negatively correlated with age (years) (r = -0.326, P < .001), waist circumference (centimeters) (r = -0.176, P = .01), body mass index (r = -0.173, P = .011), and hypertension (r = -0.186, P = .006). None of the patient characteristics were significantly correlated with percentage collapse of the IVC. Height (centimeters) was the sole significant predictor of IVCmax (R(2) = 0.079, P < .001). Age (years) and body mass index (kilogram/square meter) were independent predictors of the IVC/Ao index (R(2) = 0.123; P < .001 and P = .046, respectively). CONCLUSIONS The percentage collapse of IVC and the IVCmax are not substantially influenced by patient characteristics. In contrast, the IVC/Ao index is more susceptible to patient characteristics than IVC.
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Affiliation(s)
- Jianjun Gui
- Department of the Neurology Intensive Care Unit, the First Hospital Affiliated to Jinan University, Guangzhou 510630, Guangdong, China; Department of the General Intensive Care Unit, Dongguan Hospital Affiliated to Medical College of Jinan University, Dongguan 523905, Guangdong, China
| | - Jiongguang Guo
- Department of the Pediatric Intensive Care Unit, Dongguan Hospital Affiliated to Medical College of Jinan University, Dongguan 523905, Guangdong, China
| | - Fengqiu Nong
- Department of the Pediatric Intensive Care Unit, Dongguan Hospital Affiliated to Medical College of Jinan University, Dongguan 523905, Guangdong, China
| | - Dongxin Jiang
- Department of the General Intensive Care Unit, Dongguan Hospital Affiliated to Medical College of Jinan University, Dongguan 523905, Guangdong, China.
| | - Anding Xu
- Department of the Neurology Intensive Care Unit, the First Hospital Affiliated to Jinan University, Guangzhou 510630, Guangdong, China
| | - Fan Yang
- Department of Ultrasound, Dongguan Hospital Affiliated to Medical College of Jinan University, Dongguan 523905, Guangdong, China
| | - Qiaozhu Chen
- Department of Ultrasound, Dongguan Hospital Affiliated to Medical College of Jinan University, Dongguan 523905, Guangdong, China
| | - Youping Lin
- Department of the General Intensive Care Unit, Dongguan Hospital Affiliated to Medical College of Jinan University, Dongguan 523905, Guangdong, China
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Inferior Vena Cava Assessment: Correlation with CVP and Plethora in Tamponade. Glob Heart 2015; 8:323-7. [PMID: 25690633 DOI: 10.1016/j.gheart.2013.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 11/04/2013] [Indexed: 12/13/2022] Open
Abstract
Bedside assessment of intravascular volume status plays an important role in the management of critically ill patients, guiding fluid replacement therapy and the use of vasopressor agents. Despite controversy in the existing evidence, many clinicians advocate the use of inferior vena cava ultrasound (IVC-US) in the assessment of intravascular volume status in critically ill patients. Respirophasic variation in IVC diameter may provide useful information regarding intravascular volume status, particularly in patients with high and low caval indices. However, due to conflicting results of small-scale clinical trials of divergent sample populations, there is insufficient evidence to support routine US assessment of the IVC to determine fluid responsiveness in spontaneous breathing with circulatory compromise. Additional large-scale clinical trials are required to determine the accuracy of IVC-US measurements in diverse populations and to ascertain the effects on IVC dimensions that result from cardiac dysfunction and intra-abdominal hypertension.
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Mesin L, Pasquero P, Albani S, Porta M, Roatta S. Semi-automated tracking and continuous monitoring of inferior vena cava diameter in simulated and experimental ultrasound imaging. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:845-857. [PMID: 25638320 DOI: 10.1016/j.ultrasmedbio.2014.09.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Revised: 09/19/2014] [Accepted: 09/26/2014] [Indexed: 06/04/2023]
Abstract
Assessment of respirophasic fluctuations in the diameter of the inferior vena cava (IVC) is detrimentally affected by its concomitant displacements. This study was aimed at presenting and validating a method to compensate for IVC movement artifacts while continuously measuring IVC diameter in an automated fashion (with minimal interaction with the user) from a longitudinal B-mode ultrasound clip. Performance was tested on both experimental ultrasound clips collected from four healthy patients and simulations, implementing rigid IVC displacements and pulsation. Compared with traditional M-mode measurements, the new approach systematically reduced errors in caval index assessment (range over maximum diameter value) to an extent depending on individual vessel geometry, IVC movement and choice of the M-line (the line along which the diameter is computed). In experimental recordings, this approach identified both the cardiac and respiratory components of IVC movement and pulsatility and evidenced the spatial dependence of IVC pulsatility. IVC tracking appears to be a promising approach to reduce movement artifacts and to improve the reliability of IVC diameter monitoring.
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Affiliation(s)
- Luca Mesin
- Mathematical Biology and Physiology, Department of Electronics and Telecommunications, Politecnico di Torino, Torino, Italy.
| | - Paolo Pasquero
- Department of Medical Sciences, University of Torino, Torino, Italy
| | - Stefano Albani
- Department of Medical Sciences, University of Torino, Torino, Italy
| | - Massimo Porta
- Department of Medical Sciences, University of Torino, Torino, Italy
| | - Silvestro Roatta
- Integrative Physiology Laboratory, Department of Neuroscience, University of Torino, Torino, Italy
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