title: Jugular vein distensibility predicts fluid responsiveness in septic patients.
abstract: BACKGROUND
  The purpose of the study was to verify the efficacy of using internal jugular vein (IJV) size and distensibility as a reliable index of fluid responsiveness in mechanically ventilated patients with sepsis.
  
  
  METHODS
  Hemodynamic data of mechanically ventilated patients with sepsis were collected through a radial arterial indwelling catheter connected to continuous hemodynamic monitoring system (Most Care®, Vytech Health, Padova, Italy), including cardiac index (CI) (L/min/M(2)), heart rate (beats/min), mean arterial pressure (MAP) (mmHg), central venous pressure (CVP) (mmHg) and arterial pulse pressure variation (PPV), coupled with ultrasound evaluation of IJV distensibility (%), defined as a ratio of the difference between IJV maximal antero-posterior diameter during inspiration and minimum expiratory diameter to minimum expiratory diameter x100. Patients were retrospectively divided into two groups; fluid responders (R), if CI increase of more than or equal to 15% after a 7 ml/kg crystalloid infusion, and non-responders (NR) if CI increased more than 15%. We compared differences in measured variables between R and NR groups and calculated receiver-operator-characteristic (ROC) curves of optimal IJV distensibility and PPV sensitivity and specificity to predicting R. We also calculated a combined inferior vena cava distensibility-PPV ROC curve to predict R.
  
  
  RESULTS
  We enrolled 50 patients, of these, 30 were R. Responders presented higher IJV distensibility and PPV before fluid challenge than NR (P <0.05). An IJV distensibility more than 18% prior to volume challenge had an 80% sensitivity and 85% specificity to predict R. Pairwise comparison between IJV distensibility and PPV ROC curves revealed similar ROC area under the curve results. Interestingly, combining IJV distensibility more than 9.7% and PPV more than 12% predicted fluid responsiveness with a sensitivity of 100% and specificity of 95%.
  
  
  CONCLUSIONS
  IJV distensibility is an accurate, easily acquired non-invasive parameter of fluid responsiveness in mechanically ventilated septic patients with performance similar to PPV. The combined use of IJV distensibility with left-sided indexes of fluid responsiveness improves their predictive value.
authors.affiliation: Department of Anesthesia and Critical Care Medicine, Cardiothoracic Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria Pisana, Via Paradisa, 2 56123, Pisa, Italy. fabiodoc64@hotmail.com.
authors.forename: Fabio
authors.initials: F
authors.lastname: Guarracino
authors.affiliation: Department of Anesthesia and Critical Care Medicine, Cardiothoracic Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria Pisana, Via Paradisa, 2 56123, Pisa, Italy. baldoferro81@gmail.com.
authors.forename: Baldassarre
authors.initials: B
authors.lastname: Ferro
authors.affiliation: Department of Anesthesia and Critical Care Medicine, Anestesia e Rianimazione Universitaria IV, Azienda Ospedaliero Universitaria Pisana, Via Paradisa, 2 56123, Pisa, Italy. forforiden@libero.it.
authors.forename: Francesco
authors.initials: F
authors.lastname: Forfori
authors.affiliation: Department of Anesthesia and Critical Care Medicine, Cardiothoracic Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria Pisana, Via Paradisa, 2 56123, Pisa, Italy. pietro.bertini@gmail.com.
authors.forename: Pietro
authors.initials: P
authors.lastname: Bertini
authors.affiliation: Department of Anesthesia and Critical Care Medicine, Anestesia e Rianimazione Universitaria IV, Azienda Ospedaliero Universitaria Pisana, Via Paradisa, 2 56123, Pisa, Italy. luanam84@hotmail.com.
authors.forename: Luana
authors.initials: L
authors.lastname: Magliacano
authors.affiliation: Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. pinskymr@upmc.edu.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Pinsky
mesh_terms: D000368:Aged; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans; D007601:Jugular Veins / Q000000981:diagnostic imaging* / Q000502:physiology; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012121:Respiration, Artificial / Q000379:methods; D018805:Sepsis / Q000000981:diagnostic imaging* / Q000628:therapy*; D018084:Ultrasonography, Interventional / Q000379:methods; D014664:Vasodilation / Q000502:physiology