Major trauma patients in ICU often require aggressive fluid management. However overzealous crystalloids/blood transfusions have associated problems. Central venous pressures and arterial line waveform are not always helpful in determining need for fluids. What is your experience regarding use of Ultrasound/Echocardiographic imaging of IVC diameter changes in assessing fluid needs of these patients.
Attached is a link to online pdf of the article "Barbier C et. al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med (2004) 30:1740–1746".
http://www.slredultrasound.com/Filesandpictures/IVC2.pdf
As an Emergency Physician i find it a very useful device to have and effective in fluid depleted patient requiring critical resuscitation .
The key is expertise in scanning as always error of judgement is there as it i soperator dependent .
Thank you very much Dr Pasha..
I just wanted to know what practical problems arise in assessing patients who are in need of aggressive fluid resuscitation.. also, are any variables that affect the ability of this modality to correctly detect the need for further fluids, like positive pressure ventilation (it is the change with respiratory cycle that we look at... right?)
regards, raza
Ultrasound measurement of CVP provides a relatively easy method for a rapid estimation of changes in CVP, although absolute values may differ substantially from invasive CVP and between different investigators. When you use US to estimate the volume status of your patients you need to take into account if the patient is in spontaneous breathing or machanically ventilated. In addition PEEP increases the PVC and dilates the VCI. In hypovolemic status I think that, most of the absolute value, It is better to consider the variations in IVC diameters to the administration of fluids
I am not convinced that any of the commonly used clinical assessment tools truly estimate the patient's volume status. Some indicate ventricular filling pressures, others predict "fluid responsiveness" (etc.). Neither will tell you that adjusting the ventricular filling pressure or giving fluids is going to be the right thing to do. All these numbers that we generate have to be placed in the context of the overall clinical condition of the patient, current resuscitation goals and whether or not they have been met. It is quite feasible in a situation where a monitor is telling you that the patient will respond to intravenous fluids that commencing an inotrope or vasopressor is the best option.
I fully agree with the views of Dr Christopher Rout and endorse them.
Ultrasound guided IVC diameter measurement can be an easy, non invasive and less time consuming method for volume assessment in trauma and critically ill patients but in my opinion it has to correlated with the clinical signs constantly and a large multi-center study has to be conducted for its proper validation.
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