Predicting Fluid Responsiveness Using Bedside Ultrasound Measurements of the Inferior Vena Cava and Physician Gestalt in the Emergency Department of an Urban Public Hospital in Sub-Saharan Africa.
BACKGROUND
Bedside inferior vena cava (IVC) ultrasound has been proposed as a non-invasive measure of volume status. We compared ultrasound measurements of the caval index (CI) and physician gestalt to predict blood pressure response in patients requiring intravenous fluid resuscitation.


METHODS
This was a prospective study of adult emergency department patients requiring fluid resuscitation. A structured data sheet was used to record serial vital signs and the treating clinician's impression of patient volume status and cause of hypotension. Bedside ultrasound CI measurements were performed at baseline and after each 500mL of fluid. Receiver operating characteristic (ROC) curve analysis was performed to characterize the relationship between CI and Physician gestalt, and the change in mean arterial pressure (MAP).


RESULTS
We enrolled 364 patients, 52% male, mean age 36 years. Indications for fluid resuscitation were haemorrhage (54%), dehydration (30%), and sepsis (17%). Receiver operating characteristic curve analysis found optimal CI cut-off values of 45%, 52% and 53% to predict a MAP rise of 5, 8 and 10 mmHg per litre of fluid, respectively. The sensitivity and specificity of CI of 50% for predicting a 10mmHg increase in MAP per litre were 88% (95%CI 81-93%) and 73% (95%CI 67-79%), respectively, area under the curve (AUC) = 0.85 (0.81-0.89). The sensitivity and specificity of physician gestalt estimate of volume depletion severity were 68% (95%CI 60-75%) and 86% (95%CI 80-90%), respectively, AUC = 0.83 (95% CI: 0.79-0.87). Those with a baseline CI ≥ 50% (51% of patients) had a 2.8-fold greater fluid responsiveness than those with a baseline CI<50% (p<0.0001).


CONCLUSIONS
Ultrasound measurement of the CI can predict blood pressure response among patients requiring intravenous fluid resuscitation and may be useful in early identification of patients who will benefit most from volume resuscitation, and those who will likely require other interventions.
Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania.|Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.
Hendry Robert
http://orcid.org/0000-0002-0395-5385
HR
Sawe
School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America.
Cathryn
C
Haeffele
Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania.|Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.
Juma A
JA
Mfinanga
Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania.|Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.
Victor G
VG
Mwafongo
Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania.|Department of Emergency Medicine, University of California San Francisco, San Francisco, California, United States of America.
Teri A
TA
Reynolds
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