Ultrasound Case 015

Presentation

An elderly patient with a history of heart failure presents with sepsis and hypotension following 2 days of diarrhoea.

They received 1000mL of intravenous fluid pre-hospital of fluid and you are concerned about potential fluid overload in a patient with a history of heart failure (particularly as the optimal goals for fluid management in sepsis remain contentious…)

You decide to look at their inferior vena cava (IVC). If it is flat you will give some more fluid. If not you will need to think harder!

Longitudinal view IVC
View 2 – Transverse view IVC
Transverse view IVC

Describe and interpret these scans

IMAGE INTERPRETATION

Image 1: Longitudinal view of the IVC deep to the liver: The IVC is flat with complete collapse on inspiration and very little filling seen only during atrial systole on expiration.

Image 2: Transverse view of the IVC: The IVC again is flat with complete collapse on inspiration and minimal pulsatile filling on expiration reflecting atrial systolic IVC flow reversal.


CLINICAL CORRELATION

Hypovolaemia.

Using the IVC as the sole determinant of volume status is fraught with difficulty. Complete collapse of the IVC with associated hypotension however correlates well with volume depletion and should prompt fluid administration.

The IVC AP diameter and its variation through the respiratory cycle can be used as a rough guide to volume status. In the euvolaemic spontaneously breathing patient the IVC generally partially collapses during inspiration. This is because during inspiration negative intrathoracic pressure draws more blood into the right heart; at the same time the diaphragm descends, increasing abdominal pressure and blood from the upper abdominal IVC is propelled upwards and out of the IVC. Whilst precise measurements are quoted as being useful (greater that 50% collapse with inspiration and maximal diameter less than 2.1cm associated with hypovolaemia and less than 50% inspiratory collapse and AP diameter greater than 2.1cm associated with hypervolaemia) errors can occur. Consider cardiac tamponade as just one example where a large IVC does not necessarily correlate with hypervolaemia.

Despite the many limitations a flat IVC in the supine patient with associated hypotension is a very useful finding which does reflect volume depletion and should prompt rapid and appropriate fluid administration.


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An Emergency physician based in Perth, Western Australia. Professionally my passion lies in integrating advanced diagnostic and procedural ultrasound into clinical assessment and management of the undifferentiated patient. Sharing hard fought knowledge with innovative educational techniques to ensure knowledge translation and dissemination is my goal. Family, wild coastlines, native forests, and tinkering in the shed fills the rest of my contented time. | SonoCPDUltrasound library | Top 100 | @thesonocave |

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