Correlation of Ultrasound-Based Hydration Assessment Measures with CVP and Clinical Hydration Status among Children Admitted to the PICU: A Prospective Observational Study

Abstract

Purpose This article assesses the correlation of respiratory variation in inferior vena cava (IVC) with central venous pressure (CVP) in children. Secondary objective was to evaluate IVC variability with clinical hydration status.

Methods IVC variability was assessed at the subcostal (SC) and right lateral (RL) region, and collapsibility index (CI) (spontaneously breathing) and distensibility index (DI) (positive pressure) and IVC/aortic ratio were calculated. Partial correlations were calculated between CI/DI with CVP adjusting for body mass index and age. Sensitivity of CI and DI to predict clinical dehydration was calculated using receiver operating characteristic curves.

Results A total of 145 ultrasounds were performed on 72 patients (41% positive pressure). Only RL CI in spontaneously breathing patients strongly correlated with CVP (r = –0.65, p < 0.001). A moderate correlation was observed between CI and DI from SC and RL regions (r's = 0.38 and 0.47). Among spontaneously breathing patients, a significant difference was observed in the SC CI based on hydration status. For patients on positive pressure, IVC/aortic ratio had a significant difference. SC CI had the highest area under the curve (0.82) to detect dehydration with 80% sensitivity/87% specificity for a cutoff of 40%.

Conclusion SC CI is the most reliable measure to assess the hydration status of spontaneously breathing children, while the IVC/aortic ratio performs well for patients under positive pressure. RL CI has strong negative correlation with CVP in spontaneously breathing patients.

Keywords

ultrasound - inferior vena cava - dehydration - central venous pressure - pediatrics - intensive care unit

Note

The study was presented at the Midwest chapter of the Society of Critical Care Medicine (SCCM) virtual meeting on August 7th, 2021. It has been accepted as a STAR research award presentation for SCCM 2022 National Congress. The study was published in abstract form only in the congress supplement (Critical Care Medicine 2022;50(1S):p23).

Authors' Contributions

S.T. conceived and designed the study, participated in literature search, subject recruitment, clinical ultrasound exams, data analysis, and interpretation and wrote the manuscript. M.H. and T.O. assisted in the performance of ultrasounds and subject recruitment. K.L. assisted in statistical analysis and interpretation. D.A.W. participated in the design and conduct of the study and obtained regulatory approvals and subject recruitment. All authors approve of the manuscript as written.

Publication History

Received: 07 February 2022

Accepted: 28 February 2022

Article published online:
10 June 2022

• References

• 1 Lex DJ, Tóth R, Czobor NR. et al. Fluid overload is associated with higher mortality and morbidity in pediatric patients undergoing cardiac surgery. Pediatr Crit Care Med 2016; 17 (04) 307-314
• 2 Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011; 39 (02) 259-265
• 3 Neyra JA, Canepa-Escaro F, Li X. et al; Acute Kidney Injury in Critical Illness Study Group. Association of hyperchloremia with hospital mortality in critically ill septic patients. Crit Care Med 2015; 43 (09) 1938-1944
• 4 Evans L, Rhodes A, Alhazzani W. et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47 (11) 1181-1247
• 5 Weiss SL, Peters MJ, Alhazzani W. et al. Surviving Sepsis Campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020; 46 (1, Suppl 1): 10-67
• 6 Kinlin LM, Freedman SB. Evaluation of a clinical dehydration scale in children requiring intravenous rehydration. Pediatrics 2012; 129 (05) e1211-e1219
• 7 Airapetian N, Maizel J, Alyamani O. et al. Does inferior vena cava respiratory variability predict fluid responsiveness in spontaneously breathing patients?. Crit Care 2015; 19 (01) 400
• 8 Zhang Z, Xu X, Ye S, Xu L. Ultrasonographic measurement of the respiratory variation in the inferior vena cava diameter is predictive of fluid responsiveness in critically ill patients: systematic review and meta-analysis. Ultrasound Med Biol 2014; 40 (05) 845-853
• 9 Chen L, Hsiao A, Langhan M, Riera A, Santucci KA. Use of bedside ultrasound to assess degree of dehydration in children with gastroenteritis. Acad Emerg Med 2010; 17 (10) 1042-1047
• 10 Ng L, Khine H, Taragin BH, Avner JR, Ushay M, Nunez D. Does bedside sonographic measurement of the inferior vena cava diameter correlate with central venous pressure in the assessment of intravascular volume in children?. Pediatr Emerg Care 2013; 29 (03) 337-341
• 11 Choi DY, Kwak HJ, Park HY, Kim YB, Choi CH, Lee JY. Respiratory variation in aortic blood flow velocity as a predictor of fluid responsiveness in children after repair of ventricular septal defect. Pediatr Cardiol 2010; 31 (08) 1166-1170
• 12 Gan H, Cannesson M, Chandler JR, Ansermino JM. Predicting fluid responsiveness in children: a systematic review. Anesth Analg 2013; 117 (06) 1380-1392
• 13 Tripathi S, Ganatra H, Martinez E, Mannaa M, Peters J. Accuracy and reliability of bedside thoracic ultrasound in detecting pulmonary pathology in a heterogeneous pediatric intensive care unit population. J Clin Ultrasound 2019; 47 (02) 63-70
• 14 Levine AC, Shah SP, Umulisa I. et al. Ultrasound assessment of severe dehydration in children with diarrhea and vomiting. Acad Emerg Med 2010; 17 (10) 1035-1041
• 15 de Souza TH, Giatti MP, Nogueira RJN, Pereira RM, Soub ACS, Brandão MB. Inferior vena cava ultrasound in children: comparing two common assessment methods. Pediatr Crit Care Med 2020; 21 (04) e186-e191
• 16 Basu S, Sharron M, Herrera N, Mize M, Cohen J. Point-of-care ultrasound assessment of the inferior vena cava in mechanically ventilated critically ill children. J Ultrasound Med 2020; 39 (08) 1573-1579
• 17 Center for Clinical Research and Biostatistics. Correlation Coefficient using z-transformation. The Chinese University of Hong Kong; 2021 . Accessed December 23, 2021 at: https://www2.ccrb.cuhk.edu.hk/stat/other/correlation.htm
• 18 CDC. Adult Body Mass Index (BMI). US DEpartment of Health & Human Services. . Accessed October 25, 2020 at: https://www.cdc.gov/obesity/adult/defining.html#:~:text=If%20your%20BMI%20is%20less%20than%2018.5%2C%20it,or%20higher%2C%20it%20falls%20within%20the%20obese%20range
• 19 CDC. A SAS Program for the 2000 CDC Growth Charts (ages 0 to <20 years). Centers for Disease Control and Prevention; 2020 . Accessed March 15, 2022 at: https://www.cdc.gov/nccdphp/dnpao/growthcharts/resources/sas.htm
• 20 Lund A, Lund M. Pearson Product-Moment Correlation. Laerd Statistics. 2021 . Accessed December 23, 2021 at: https://statistics.laerd.com/statistical-guides/pearson-correlation-coefficient-statistical-guide.php
• 21 Sun S, Ren H, Wang Y. et al. Respiratory variations in aortic blood flow to predict volume responsiveness in ventilated children with leukemia and neutropenic septic shock. Pediatr Crit Care Med 2020; 21 (05) e247-e252
• 22 Koves IH, Neutze J, Donath S. et al. The accuracy of clinical assessment of dehydration during diabetic ketoacidosis in childhood. Diabetes Care 2004; 27 (10) 2485-2487
• 23 Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013; 41 (07) 1774-1781
• 24 Nagdev AD, Merchant RC, Tirado-Gonzalez A, Sisson CA, Murphy MC. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. Ann Emerg Med 2010; 55 (03) 290-295
• 25 Lee CK, Margossian R, Sleeper LA. et al; Pediatric Heart Network Investigators. Variability of M-mode versus two-dimensional echocardiography measurements in children with dilated cardiomyopathy. Pediatr Cardiol 2014; 35 (04) 658-667
• 26 Tchernodrinski S, Arntfield R. Inferior vena cava. In: Soni N, Arntfield R, Kory P. eds. Point of Care Ultrasound. Elsevier; Philadelphia: 2015: 135-141
• 27 Weber T, Wagner T, Neumann K, Deusch E. Low predictability of three different noninvasive methods to determine fluid responsiveness in critically ill children. Pediatr Crit Care Med 2015; 16 (03) e89-e94
• 28 EL-Nawawy AA. Omar OM, Hassouna HM. Role of inferior vena cava parameters as predictors of fluid responsiveness in pediatric septic shock: a prospective study. J Child Sci 2021; 11 (01) e49-e54
• 29 Bilgili B, Haliloglu M, Tugtepe H, Umuroglu T. The assessment of intravascular volume with inferior vena cava and internal jugular vein distensibility indexes in children undergoing urologic surgery. J Invest Surg 2018; 31 (06) 523-528
• 30 Chen L, Kim Y, Santucci KA. Use of ultrasound measurement of the inferior vena cava diameter as an objective tool in the assessment of children with clinical dehydration. Acad Emerg Med 2007; 14 (10) 841-845
• 31 Kwon H, Jung JY, Lee JH. et al. Sonographic aorta/IVC cross-sectional area index for evaluation of dehydration in children. Am J Emerg Med 2016; 34 (09) 1840-1844
• 32 Valette X, Ribstein P, Ramakers M, du Cheyron D. Subcostal versus transhepatic view to assess the inferior vena cava in critically ill patients. Echocardiography 2020; 37 (08) 1171-1176
• 33 Shah R, Spiegel R, Lu C, Crnosija I, Ahmad S. Relationship between the subcostal and right lateral ultrasound views of inferior vena cava collapse: implications for clinical use of ultrasonography. Chest 2018; 153 (04) 939-945