Dissections DIAGNOSIS

19 August 2009
Evidence-based Medicine for Surgeons

Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in estimating

intravascular volume status: correlations with CVP
Authors: Stawicki SP, Braslow BM, Panebianco NL, et al
Journal: J American College of Surgeons 2009; 209: 55–61
Centre: University of Pennsylvania School of Medicine, Philadelphia, PA, USA
Clinical examination is known to be unreliable in the evaluation of intravascular volume, leading
to the need for more objective means of assessment. Recent technological advances have made
ultrasonography equipment compact, mobile, easy to use, and inexpensive. Clinician-performed
bedside ultrasonography examinations have become popular methods of round-the-clock, rapidly
BACKGROUND deployed strategies for initial assessment and guide to subsequent therapy in a wide range of
acute clinical situations. Intensivist-performed bedside ultrasonography (INBU) has been used in
evaluation of the circulating volume status in critically ill patients. One widely used parameter in
IVC assessment of intravascular volume is the IVC collapsibility index (IVC-CI).

RESEARCH QUESTION IN SUMMARY

Population IVC collapsibility index (IVC - CI) versus CVP

Adult patients admitted to a high- Number Mean CVP (mm Hg)

acuity, surgical intensive care unit.
IVC-CI group
Indicator variable High (> 0.6) 13 7.40
IVC collapsibility index (IVC-CI) Intermediate (0.2 - 0.6) 41 9.75
measured by intensivist-performed
bedside ultrasonography (INBU) Low (< 0.2) 29 12.0
using a hand-carried An IVC-CI in the intermediate range (0.20 - 0.60) was not helpful in
ultrasonography unit. discriminating CVP

Outcome variable
Authors' claim(s): “...Measurements of IVC-CI by INBU can provide a
Primary: circulating volume status useful guide to noninvasive volume status assessment in SICU patients. ...
Additional studies are needed to confirm and expand on findings of this
Comparison study.”
CVP measurement.

THE TISSUE REPORT

Let's first set aside the flaws in this study; there
are many and are easily spotted. The authors
are quick to state that "large-scale prospective
studies will be needed to confirm and expand
on the findings of the present study". This
study enlarges the growing list of physician-
performed, bedside ultrasound assessments
that add value to the process of decision
making in acute situations. Future reports on
this matter will clarify the value of this study.
IVC-CI consists of the difference between the end-expiratory (IVCD-
exp) and end-inspiratory IVC diameter (IVCD-insp) divided by IVCD-
exp. IVC diameter measurement is obtained using M-mode
ultrasonography. Studies have shown an inverse relationship
between IVC-CI and right atrial (RA) pressure or CVP, where higher
IVC-CI values correlate with low RA filling pressures (low CVP) and
lower IVC-CI values correlate with higher RA filling pressures.
For eg. if IVCD-exp = 18.3 mm and IVCD-insp = 3.8mm, the IVC-CI
would be (18.3 - 3.8)/18.3, or 0.792.

EBM-O-METER
Evidence level Overall rating Bias levels
Double blind RCT Sampling
Randomized controlled trial (RCT) Comparison
Trash Swiss Safe News-
Prospective cohort study - not randomized cheese worthy Measurement
Life's too Holds water
short for this Full of holes “Just do it”
Case controlled study
Interestingl | Novel l | Feasible l
Case series - retrospective  Ethical l | Resource saving l

The devil is in the details (more on the paper) ... 

© Dr Arjun Rajagopalan
 SAMPLING
Sample type Inclusion criteria Exclusion criteria Final score card
Simple random Adult (older than Not stated IVC-CI vs CVP study
18) patients
Stratified random Target ?
admitted to an SICU
Cluster who had a CVP Accessible 124
catheter placed 
Consecutive Intended 101
Convenience Drop outs 18
Judgmental Study 83

 = Reasonable | ? = Arguable |  = Questionable

Duration of the study: October 2006 and April 2007

Sampling bias: The drop off between accessible patients and the study group is very large. This is a single centre
experience.

COMPARISON
Randomized Case-control Non-random Historical None

Controls - details
Allocation details The INBU-derived measurements of IVC-CI were compared with invasively measured CVP.
After completion of the ultrasonography examination, members of the SICU team caring for
the patient, blinded to ultrasonography findings, provided data on a standardized form about
patient demographics, vital signs, and invasive hemodynamic monitoring variables obtained at
the time of the examination.
Comparability -
Disparity -

Comparison bias: -

MEASUREMENT
Measurement error
Device used Device error Observer error
Gold std.

Device suited to task

Training

Scoring

Blinding
Repetition

Protocols

Y ? N

1.IVC-CI by INBU ? N ? Y Y N Y

All intensivists had earlier ultrasonography experience in general bedside sonography (including focused assessment
with sonography for trauma, gallbladder, aorta, and first-trimester pregnancy evaluations) and an additional 3 hours of
didactic review of the techniques of acquisition and interpretation of sonographic images of the heart and IVC.
A record of each examination was stored in the form of static images and 6-second digital video clips. Sonographers
recorded their interpretation of each examination and completion times on a standardized form blinded to the results of
all invasive and noninvasive monitoring data.
IVC-CI was defined in one of two ways, depending on whether or not the patient was intubated.
IVC-CI measurements were grouped by range (<.20, 0.20 to 0.60, and >0.60). CVP values were also grouped into
three ranges: <7 mmHg, 7 to 12 mmHg, and >12 mmHg.

Measurement bias: There was no attempt to measure observer variability: a critical element of bias in these
studies. The grouping of CVP by three ranges is arbitrary. CVP is well known to have no standardizable normal
ranges.

© Dr Arjun Rajagopalan