title: The caval index: an adequate non-invasive ultrasound parameter to predict fluid responsiveness in the emergency department?
abstract: BACKGROUND
  Fluid therapy is the first important step in patients with signs of shock but assessment of the volume status is difficult and invasive measurements are not readily available in the emergency department. We have investigated whether the respiratory variation in diameter of the inferior vena cava is a reliable parameter to predict fluid responsiveness in spontaneous breathing emergency department patients with signs of shock.
  
  
  METHODS
  All patients admitted to the emergency department during a 15 week period were screened for signs of shock. If the attending physician planned to give a fluid challenge, the caval index was determined by transabdominal ultrasonography in supine position. Immediately afterwards 500 ml NaCl 0.9% was administered in 15 minutes and the clinical response was observed. An adequate response was defined as an increase in systolic blood pressure of at least 10 mm Hg. Based on this definition patients were divided into responders and non-responders.
  
  
  RESULTS
  After selection a total number of 45 patients was included. A low caval index (< 36.5%) in patients with signs of shock reliably predicted the absence of an adequate response to fluid therapy (negative predictive value 92%). The positive predictive value of a high caval index was much lower (48%) despite the fact that responders had a significantly higher pre-infusion caval index than non-responders (48.7% vs 31.8%, p 0.014).
  
  
  CONCLUSIONS
  In spontaneously breathing patients with signs of shock in the emergency department, a high caval index (>36.5%) does not reliably predict fluid responsiveness in our study, while a low caval index (<36.5%) makes fluid responsiveness unlikely. An explanation for the absence of a blood pressure response in the group of patients with a low high caval index might be that these patients represent a group requiring more volume therapy than 500 ml.
authors.affiliation: Emergency Department, Department of Internal Medicine, University Medical Center Groningen, UMCG, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
authors.forename: Silke
authors.initials: S
authors.lastname: de Valk
authors.affiliation: Emergency Department, Department of Internal Medicine, University Medical Center Groningen, UMCG, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
authors.forename: Tycho Joan
authors.initials: TJ
authors.lastname: Olgers
authors.affiliation: Emergency Department, University Medical Center Groningen, UMCG, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
authors.forename: Mirjam
authors.initials: M
authors.lastname: Holman
authors.affiliation: Department of Critical Care, University Medical Center Groningen, UMCG, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
authors.forename: Farouq
authors.initials: F
authors.lastname: Ismael
authors.affiliation: Emergency Department, Department of Internal Medicine, University Medical Center Groningen, UMCG, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
authors.forename: Jack Johannes Maria
authors.initials: JJ
authors.lastname: Ligtenberg
authors.affiliation: Emergency Department, Department of Internal Medicine, University Medical Center Groningen, UMCG, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
authors.forename: Jan Cornelis
authors.initials: JC
authors.lastname: Ter Maaten
mesh_terms: D000005:Abdomen / Q000000981:diagnostic imaging*; D000328:Adult; D000368:Aged; D001794:Blood Pressure / Q000502:physiology; D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012772:Shock, Septic / Q000000981:diagnostic imaging* / Q000628:therapy*; D014463:Ultrasonography
keywords: Emergency department; Fluid responsiveness; Inferior vena cava; Shock; Ultrasound
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