UZ donje suplje vene u

procjeni volumena cirkulisuce

krvi
indikacije
• Diagnoza
• PROCJENA CIRKULISUCEG VOLUMENA
• smanjenje (cirkulisuci sok, dehidratacija
• povecanje (kongestivna srcana insuficijencija)
• predvidjanje promjene cirkulisuceg volumena npr nakon primjene
terapije - serijski monitoring (sepsa): ponavljati UZ nakon primjene
svakog bolusa tecnosti
pristup
• Subcostalni Longitudinalni
• Pearls to improve view window
• View improves with the patient taking a deep inspiration
• Transducer orientation
• Transducer placed right lateral to sub-xiphoid - indicator pointed towards
12:00 with energy toward left atrium
• Landmarks: Inferior vena cava I Right atrium
 Volume status based on IVC alone
(Respirophasic IVC Variation)
• Inferior vena cava (IVC) is normally 1.5 to 2.5 cm in diameter (measured 3 cm from right
atrium)
• IVC <1 cm in Trauma is associated with a high likelihood of Hemorrhage requiring Blood Transfusion
• IVC <1.5 cm suggests volume depletion A >2.5 cm suggests volume overload
• Inferior vena cava (IVC) normally collapses more than 50% with inspiration or sniffing
• Consider measuring in M-Mode
• Caval Index = (IVC-exp diameter - IVC insp diameter) / (IVC-exp diameter) * 100
• Collapse <50% suggests volume overload AND Caval Index >50% suggests fluid responsiveness
• Correlation between RA pressure (CVP) and IVC appearance
• CVP 0-5 cm: IVC totally collapses on inspiration and is <1.5 cm in diameter
• CVP 5-10 cm: IVC collapses >50% on inspiration and is 1.5 to 2.5 cm in diameter
• CVP 11-15 cm: IVC collapses <50% on inspiration and is 1.5 to 2.5 cm in diameter
• CVP 16-20 cm: IVC collapses <50% on inspiration and is >2.5 cm in diameter
• CVP >20 cm: No change in IVC on inspiration and is >2.5 cm in diameter
Volume status by Caval Aorta Index
• Step 1: Measure maximal internal IVC anteroposterior diameter (in M
Mode)
• Subxiphoid level in longitudinal axis
• Measure just caudal to confluence of hepatic veins (~3 cm from right atrium)
• Step 2: Measure maximal internal aorta anteroposterior diameter (in M
Mode)
• Subxiphoid region in longitudinal axis - measure just to the left of the IVC
• Step 3: Calculate the Caval Aorta Index as IVC/Ao
• CVP <7 cm H2O: Caval Aorta Index of 0.72 (+/- 0.09)
• CVP 8-12 cm H2O: Caval Aorta Index of 1.23 (+/- 0.12)
• CVP >13 cm H2O: Caval Aorta Index of 1.59 (+/- 0.05)
 VI. Interpretation: Distensibility Index (DI)
Indication
• Assess fluid responsiveness (expected status change following fluid bolus)
in a mechanically ventilated patient
Contraindications (cases in which DI is unreliable)
• Spontaneous respirations during Mechanical Ventilation
• Tidal Volume <7 ml/kg Ideal Body Weight (based on gender and height)
• Non-sinus rhythm
• Right ventricular dysfunction
Mechanism
• Mechanical Ventilator generates positive pressure with each breath that
distends the IVC
• Positive Pressure Ventilation increases intrathoracic pressure and
decreases venous return to the right atrium
• Inferior vena cava distends with PPV delivered breath due to resistance to
right atrial filling
• Inferior vena cava returns to baseline diameter between ventilations
• Contrast with IVC collapse with spontaneous breaths (generates negative
chest pressure)
Step 1: Set-up M-Mode view of Inferior vena cava (IVC) for
anteroposterior diameter measurements
• Subxiphoid level in longitudinal axis
• Visualize inferior vena cava as it enters right atrium
• Set M-Mode caliper marker at a point 3 cm from the right atrium along
the anterior surface of the inferior vena cava
• Measure just caudal to confluence of hepatic veins (~3 cm from right
atrium)
Step 2: Obtain anteroposterior diameter measurements of IVC at
maximal and minimal diameters
• Measure maximal internal IVC anteroposterior diameter (inspiratory,
Positive Pressure Ventilation phase)
• Measure minimal internal IVC anteroposterior diameter (expiratory
phase)
Step 3: Calculate Distensibility Index (DI)
• DI = (maxIVC - minIVC) / minIVC
• Step 4: Interpretation
• Distensibility Index <18% indicates patient is not volume responsive
(unlikely to benefit from fluid bolus)
 VII. Protocol: Prediction of Volume
Responsiveness (predict response to IV fluid bolus)
Technique Inferior Vena Cava Ultrasound
• Obtain initial maxium and minimum IVC
measurements Video (SonoSite)
• Perform Passive Leg Raise Maneuver (PLR Maneuver)
• Repeat maxium and minimum IVC measurements

Interpretation
• Improved hemodynamic parameters by IVC
measurement suggests volume responsiveness http://www.youtube.com/watch?
(benefit with fluid bolus) v=ci9W4MvyMHI
Other IVC-related measures of fluid responsiveness
• See Distensibility Index (above)
• See Respirophasic IVC Variation (above)
Demonstration of inferior vena cava (IVC) collapsibility. In this example,
the difference between maximum IVC diameter (left, large arrow) and the
minimum IVC diameter (right, small arrow) is >50 %, indicating relatively
" low " volume status. Lack of
fluid resusc
uz vci