Justin Bowra gave a fantastic lecture on the use of IVC ultrasound at SMACC.

Here is the audio, if you want to hear the original lecture:

There was a post on Life in the Fast Lane by Justin as well.

His slides from the talk are here:

Now let's get to the SMACCing back…

I agree with 90% of Justin's talk, but as to the other 10%:

D-Dimer????

Mech Ventilated Patients

Collapse???

Diagnosis of Undifferentiated Shock

Quick look at size and collapsibility gives huge amounts of information

Fluid Responsiveness

Need a strategy for Spontaneously Breathing Patients

1. Go bronze and give a bunch of fluid until you feel slightly uncomfortable
2. Then go for the silver and resus until IVC starts to lose easily discernible collapse (20-30%)
3. If you want to be really cool, at this point go for the gold-use some marker of stroke volume to see if additional fluid will be of benefit (either with empiric add. bolus or passive leg raise). If you want to be lazy, just put them on some norepi at this point.

Now if you use this strategy, you need to look at the operator receiver thingy-me-bobs [sic]

Spont. breathing IVC-CI trials fail due to the misfounded desire for dichotomy.

Lanspa

(Lanspa M et al. Shock 2013. 39(2). pp. 155-160)

Muller

(Muller L et al. Critical Care 2012, 16:R188)

This makes sense as respiratory-dynamic CVP demonstrates the same thing (Shock 2006;26(2):140)

Confounders:
Splint IVC open-Tamponade, Tension PTX, Massive PE, Status Asthmaticus, Right heart disease

Don't sniff test, don't tell the pt to do weird abdominal yoga breathing

Fluid Tolerance

IVCCI 15% had good accuracy (92% sens/84% spec) for CHF (Blehar et al. The American Journal of Emergency Medicine 2009;27(1):71)

and (Miller at al. Am J Emerg Med 2012;30:778) showed similar text characteristics.

by all means add in the Lichtenstein Lung Ultrasound, but only if negative when you start

We need more and better Studies

• Get a bunch of sick patients
• Do an IVCCI with a cut off of something like 30%
• Give fluid (500-1000 ml crystalloid)
• See if there was a 15% increase in SVi with a REAL cardiac output monitor or skilled evaluation of LV VTI
• AND
• see if there was a >5 mm Hg increase in arterial line MAP

and now on to the SMACC Down…

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Scott Weingart

Editor-in-Chief, EMCrit.org at EDECMO LLC

An ED Intensivist from NY. No conflicts of interest (coi).

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