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ULTRASOUND OF INFERIOR VENA CAVA

ULTRASOUND OF INFERIOR VENA CAVA. OBJECTIVES. Describe indications for using ultrasound at the bedside to image the inferior vena cava. Describe how to performing bedside ultrasound of the inferior vena cava. Use the findings on ultrasound to guide assessment of intravascular volume status.

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ULTRASOUND OF INFERIOR VENA CAVA

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  1. ULTRASOUNDOFINFERIOR VENA CAVA

  2. OBJECTIVES Describe indications for using ultrasound at the bedside to image the inferior vena cava. Describe how to performing bedside ultrasound of the inferior vena cava. Use the findings on ultrasound to guide assessment of intravascular volume status. Generate group discussion regarding the potential value of learning this procedure for patient management

  3. CASE 46 M was admitted with alcoholic hepatitis and newly diagnosed cirrhosis with ascites. On exam he had flat JVD in supine position, tense abdominal distension, and moderate leg edema to the knees. He was started on a 28 day Trental protocol Hospital Course Day 1-9 - 3 paracenteses; - removal of 11 liters of ascitic fluid. Day 10 - JVD flat in supine position - Abdomen still distended but not tense - moderate leg edema - Na = 136, Cr = 1.0, BUN = 11 - furosemide started at 20 mg QD - spironolactone started at 50mg QD.

  4. CASE Day 12 - JVD flat in supine position - persistent leg edema - apparent increase in abdominal girth on exam - Na = 134, Cr = 0.7, BUN = 12 - furosemide increased to 40mg QD Day 19 - JVD flat in supine position - persistent leg edema - abdominal girth same to slightly decreased - Na = 136, Cr = 0.8, BUN = 12 - furosemide increased to 80mg QD - spironolactone increased to 200mg QD

  5. CASE Day 21 - JVD flat in supine position - leg edema the same - Abdominal girth the same - Na = 130, Cr = 0.9, BUN = 10 Day 24 - JVD flat in the supine position - leg edema the same - Abdominal girth the same to slightly increased - Na = 127, Cr = 0.7, BUN = 13, Urine Na < 10 Daily weights and Input/Output measures were collected sporadically and could not be assessed for any trends.

  6. CLASSIC HYPONATREMIA Hypovolemic Euvolemic Hypervolemic UNa UOsm > SOsm UNa > 40 UNa < 10 > 20 YES NO < 10 > 20 Volume Depletion Mineralcorticoid Deficiency SIADH OTHER Cirrhosis Nephrosis CHF CKD Fluid Restriction plus Diuretics Volume Replacement Fluid Restriction

  7. QUESTION What type of hyponatremia does this patient have and how should it be managed? Hypovolemichyponatremia stop diuretics; begin normal saline infusion; liberalize po fluid intake; monitor Na over the course of the next several days; if Na does not improve or worsens, entertain hypervolemichyponatremia as the cause Hypervolemichyponatremia increase the diuretics and tighten the fluid restriction; monitor Na over the course of the next several days; if Na does not improve or worsens, entertain hypovolemichyponatremia as the cause. Not sure consult nephrology for an opinion about the hyponatremia

  8. INDICATIONS IVC Ultrasound Spontaneously Breathing Mechanical Ventilation Volume Status / CVP Fluid Responsiveness

  9. INDICATIONS Assessing Intravascular Volume Status / CVP • VOLUME DEPLETED STATES • - Hyponatremia • Acute Kidney Injury (? Prerenal) • Diuretic therapy • Sepsis • VOLUME OVERLOAD STATES • Hyponatremia • Heart Failure • Cirrhosis with ascites • Anasarca

  10. INDICATIONS Assessing Fluid Responsiveness in Shock - IVC diameter does not correlate with right atrial pressure in patients who are intubated with shock - Measuring the variation in IVC diameter in these situations can help determine whether the patient’s blood pressure will respond to fluids or whether inotropic support (i.e. dobutamine) will be needed

  11. Anatomy The inferior vena cava returns blood from the body to the right atrium Formed by the convergence of the illiac veins Retroperitoneal Right of the aorta Normal size <2.5 cm Varies w respiration

  12. Respiratory variation Expands w/ expiration Contracts w/ inspiration Due to changing intrathoracic pressures.

  13. Respiratory Variation Figure 2: Physiological respiratory variations in IVC diameter in a healthy volunteer breathing quietly.: From: http://www.pifo.uvsq.fr/hebergement/webrea/index.php?option=com_content&task=view&id=36&Itemid=93 IVC diameter decreases on each inspiration. http://www.criticalecho.com/content/tutorial-4-volume-status-and-preload-responsiveness-assessment

  14. Measuring the IVC Diameter Measure IVC 2cm distal to right atrium

  15. Inspiratory (Minimal) IVC Diameter

  16. Maximum (Expiratory) IVC Diameter

  17. M-Mode IVC Diameters

  18. CAVAL INDEX (CI) maximum (expiratory) diameter minimal (inspiratory) diameter CI = maximum (expiratory) diameter

  19. CAVAL INDEX (CI) 0% 100% Volume Overload Volume Depletion

  20. IVC v CVP

  21. M-Mode Volume Depletion

  22. M-Mode Volume Overload

  23. IVC v CVP

  24. PROCEDURE Positioning • Supine • Degree of head elevation has not been shown to make a significant difference in measurements

  25. PROCEDURE • Probe Selection • Low frequency 2-5 MHz • Curvalinear probe

  26. PROCEDURE Approach #1 – Xiphoid View

  27. PROCEDURE Landmarks Aproach #1 – Xiphoid View • Most common approach • Place probe longitudinally just below the xiphoid process with the probe marker to the patient’s head • Look for IVC going into right atrium – may need to move probe 1-2cm to patient’s right and then tilt it slightly towards the heart

  28. IVC Longitudinal

  29. PROCEDURE Approach #2 – Anterior Mid-Axillary View

  30. PROCEDURE Landmarks Aproach #2 – Anterior Mid-Axillary View • Place probe longitudinally in right anterior mid-axillary line with marker towards the head • Look for IVC running longitudinally adjacent to liver crossing the diaphragm. • Track superiorly until it enters right atrium confirming that it is the IVC and not the aorta.

  31. IVC Anterior Mid-Axillary View

  32. PEARLS Bowel Gas • May impede visualization in the xiphoid view • Gentle graded pressure may help move bowel out of way • Don’t press too hard or will collapse IVC causing false measurements • Consider anterior mid-axillary view

  33. PEARLS Plethoric (dilated/sluggish) IVC • Volume overload • Cardiactamponade • Mitral regurgitation • Aorticstenosis

  34. PEARLS Mechanical Ventilation • Causes reversal of IVC changes with respiration • Maximum diameter with inspiration, minimum diameter with expiration

  35. Aorta Thick, echogenic walls Pulsatile High flow velocity Not compressable No respiratory variation Above vertebral bodies IVC Thin walls Usually not pulsatile Low flow velocity Compressable Respiratory variation Right of vertebral bodies PEARLS • IVC v Aorta

  36. Aorta – Longitudinal View

  37. SonoSite 180 Plus

  38. SonoSite 180 Plus

  39. SonoSite 180 Plus Changing and Inserting the Transducer

  40. SonoSite 180 Plus Insert the transducer Twist lock counterclockwise

  41. SonoSite 180 Plus Fold lock down

  42. SonoSite 180 Plus Ready to power-up machine

  43. SonoSite 180 Plus Power Button

  44. SonoSite 180 Plus

  45. SonoSite 180 Plus

  46. SonoSite 180 Plus

  47. SonoSite 180 Plus • Wrong Transducer is Connected • Correct Transducer Menu • GYN • OB • Abdominal

  48. SonoSite 180 Plus 2D View (default) M-Mode

  49. SonoSite 180 Plus GAIN Changes the contrast on the screen

  50. SonoSite 180 Plus

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