A point-of-care ultrasound (POCUS) is a type of bedside ultrasonographic assessment that is applied by the clinician in charge(1). It provides rapid and real-time answers about patients’ clinical problems. The use of POCUS by clinicians has become common in recent years, especially in emergency and intensive care departments(2). Around the world, the number of POCUS training courses intended for pediatric intensive care and emergency care specialists is increasing, and the newest generation of pediatricians has an interest in POCUS application. In fact, in recent years, POCUS has become part of the process of physically examining critically ill children in pediatric intensive care units (PICUs)(3). Through POCUS results, clinicians are able to manage treatment options without requiring external consultation. The technique has many important advantages, for example it is easy to use, and can be repeated. It is also noninvasive, inexpensive, painless, and radiation-free(1). Most pediatric intensive care societies, including the European Society of Pediatric and Neonatal Intensive Care (ESPNIC), provide advanced training courses, and encourage a new generation of pediatric intensive care specialists to use POCUS. The ESPNIC has also published international evidence-based guidelines on POCUS for neonates and children who are seriously ill. The organization has recommended using POCUS in intensive care units based on strong evidence(4).
There are different types of POCUS applications that are commonly used. These include critical-care echocardiography (to evaluate myocardial contractility and cardiac index measurements or detect pericardial tamponade), lung ultrasounds (to evaluate pneumothorax, pleural effusion and pneumonia, and ultrasound-guided thoracentesis), vascular ultrasounds (to insert a central venous catheter, peripheral venous catheter, or invasive arterial catheter), optic nerve sheath diameter measurements (for the clinical follow-up of increased intracranial pressure), fast intraabdominal assessments (to detect perihepatic or perisplenic hemorrhage), inferior vena cava (IVC) maximum and minimum diameter measurements (to evaluate the volume status of patients), confirmation of endotracheal tube and nasogastric tube placement, and management of cardiopulmonary resuscitation(5–12).
Critically ill patients in PICUs frequently have critical and urgent problems. This patient group requires closer follow-up and needs quick assessments due to their hemodynamically unstable situation(13). Detecting volume status and planning appropriate fluid therapy as well as inotropic, vasopressor, and inodilator treatments is vitally important, especially for patients in shock(13). Appropriate fluid therapy is an important step in reducing the morbidity associated with multiple organ failure and mortality(14). Skin turgor, heart rate, mean arterial pressure, urine output, and central venous pressure (CVP) are variables used to assess the patient’s intravenous fluid status(15). There are increasingly more studies, however, which suggest that the results obtained from these variables differ depending on personal assessments. This has raised the need for new methods to find more objective results about the volume status of critically ill children(16).
The IVC is a vessel that is highly sensitive to fluid changes. It is collapsible, and varies in size depending on respiratory changes under intrathoracic pressure. During spontaneous breathing, the vessel closes on inspiration and opens on expiration. The IVC diameter can be measured by a POCUS quickly, non-invasively, and easily, and it is a critical parameter in assessing the patient’s fluid status(17). Several studies on adults have demonstrated that changes in the IVC diameter can be used to determine the patient’s fluid status, but data obtained from children are still limited(18,19).
In this article, we aim to give detailed information about IVC diameter measurement methods as well as calculations of the IVC collapsibility index (in spontaneously breathing patients) and the IVC distensibility index (in mechanically ventilated patients). We want to review the role of these measurements in the PICU setting, and emphasize the importance of a noninvasive, bedside, and objective method of detecting the volume status of critically ill patients for pediatric intensive care specialists based on the published literature.
IVC collapsibility (in spontaneously breathing patients) and IVC distensibility (in mechanically ventilated patients) indices are measured by bedside ultrasonography. Measurements are performed while the patient is in the supine position. Generally, a 2–5-MHz convex probe is used for the assessment. A sterile ultrasound gel is placed over the transducer at room temperature to obtain high-quality images. IVC images are acquired in the sagittal section. To obtain a sagittal image, the probe is placed in the subxiphoid area and the liver is used as an acoustic window. Images of the IVC draining into the right atrium are obtained while the probe is in the subxiphoid area (Fig. 1). The minimum IVC diameter on inspiration and the maximum IVC diameter on expiration are recorded using M-mode just beyond the point where the hepatic veins drain into the IVC (Fig. 2). The maximum IVC diameter on inspiration and the minimum IVC diameter on expiration are measured using the same ultrasonographic method in intubated children for the vena cava distensibility index(19). The IVC collapsibility index is calculated by the following formula: IVC collapsibility index = [maximum diameter on expiration – (minimum diameter on inspiration/maximum diameter on expiration)](20). In mechanically ventilated patients, the IVC distensibility index is calculated using the formula: IVC distensibility index = [(maximum diameter on inspiration–minimum diameter on expiration)/minimum diameter on expiration](21).
Although there is a wide range of literature on adult patients, studies on pediatric patients are still limited, though an increasing number of studies look promising(19). Again, pediatric data about these reference values are limited(22). Because of the lack of literature for pediatric age groups, the reference values defined for the IVC collapsibility index and the maximum and minimum diameters of IVC are derived from the adult population. In adults, an IVC collapsibility index of greater than 50% is associated with reduced right atrial pressure and severe dehydration, and indicates that the patient needs fluid therapy(23). Mannarino
CVP is a standard of care for evaluating the fluid status in the PICU, and it is still commonly used in critical pediatric patients(15). It reflects the right ventricular filling pressure, and provides information about the intravascular volume(28). However, the feasibility and efficacy of measuring CVP are often questioned because of risks associated with its invasive nature, such as infection, pneumothorax, and hemothorax, as well as commercial differences. These all depend on personal assessments(29).
In recent years, more studies have found and emphasized the subjectivity and decreased reliability of CVP for detecting volume status(29). The correlation between the IVC diameter and the right atrial pressure was first described in 1979 by Natori
Positive-pressure ventilation elevates the pleural and right atrial pressure values. It also reduces the venous return to the heart by increasing the intrathoracic pressure during inspiration. These factors act on the diameter and distensibility of the IVC. Finally, the IVC diameter dilates during inspiration and contracts during expiration in an intubated patient, unlike in spontaneously breathing patients(34). Therefore, it is recommended that the IVC distensibility index be used instead of the IVC collapsibility index in patients undergoing positive-pressure mechanical ventilation(35). Pediatric data are limited, and the IVC distensibility index is a new term in pediatric practice. For this reason, both Babaie
IVC collabsibility index | IVC distensibility index | ||
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Volume status assessment in spontaneously breathing patients | Volume status assessment in mechanically ventilated patients | |
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IVC images are acquired in the sagittal section. |
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Minimum IVC diameter on inspiration and maximum IVC diameter on expiration are measured. | Maximum IVC diameter on inspiration and minimum IVC diameter on expiration are measured. | ||
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(Maximum diameter on expiration – minimum diameter on inspiration) |
Maximum diameter on inspiration – minimum diameter on expiration |
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Quick, non-invasive, easy, repeatable, trustworthy and objective method for volume status evaluation17 | ||
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There are no well-determined limits for the IVC collapsibility index and distensibility index in the pediatric age group in the published literature. |
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In conclusion, the collapsibility and distensibility indices of the IVC are ultrasonographic measurement methods that are noninvasive, quick, radiation-free, and can be done at the patient’s bedside. Despite the lack of certain and reliable reference values of the IVC diameters as well as the IVC collapsibility and distensibility indices, an increasing number of studies with large patient groups will contribute to the literature on pediatric patients. Although there are opposing views, considering the lost prestige and reduced popularity of CVP, we believe that these measurement methods to evaluate the volume status of critical pediatric patients are increasingly coming to the fore in intensive care units.