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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 100-103

Comparison between femoral vein diameter and inferior vena cava diameter by ultrasound in estimation of central venous pressure in mechanically ventilated patients


1 Department of Critical Care Medicine, Faculty of Medicine, Alexandria University, Alexandria, Egypt
2 Department of Chest Disease, Faculty of Medicine, Alexandria University, Alexandria, Egypt

Date of Submission02-Jan-2019
Date of Acceptance29-Apr-2019
Date of Web Publication16-Apr-2020

Correspondence Address:
Dina Zidan
MD Critical Care, Alexandria University, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_1_19

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  Abstract 

Background Bedside ultrasonography is used as a noninvasive method for hemodynamic monitoring, evaluation of inferior vena cava (IVC) diameter by sonography provides an alternative tool for evaluation of intravascular volume. Femoral vein is a superficial compliant vessel, and images can be easily obtained. A significant correlation between central venous pressure (CVP) and common iliac vein pressure was reported previously, meaning that the femoral vein could be a noninvasive alternative to the CVP.
Patients and methods We enrolled 100 adult patients in this study. During measurement, the patient was in supine position. The CVP was uniformly measured at the end of expiration, with the pressure transducer having been zeroed at the level of mid axillary line. IVC image was obtained using General Electric ultrasound machine and 3.5-MHz convex probe. The transducer is placed in a vertical plane in the subxiphoid view. The intrahepatic portion of the IVC was visualized as it entered the right atrium. Approximately 3–4 cm from the junction of the IVC and right atrium, the IVC diameter was obtained. Using M mode, the maximum and minimum diameter during inspiration and expiration diameter were recorded, respectively. To get the femoral vein diameter (FVD), we scanned the femoral triangle starting at the inguinal crease using a linear array transducer (5–10 MHz). FVD was measured just caudal to the saphenofemoral junction.
Results We enrolled 100 patients in this study. Their mean age was 56 years, mean CVP was 6 cm H2O, mean IVC diameter during inspiration was 15 cm, whereas during expiration was 13.6 cm, and the FVD was 8.2 cm. There were significant correlations between both CVP and IVC diameter (insp and exp) and FVD. CVP correlation with FVD was 0.59, IVC diameter during inspiration with FVD was 0.41, and IVC diameter during expiration with FVD was 0.42.
Conclusion FVD can be used as a noninvasive alternative method to assess intravascular volume status.

Keywords: CVP. inferior vena cava, femoral vein, hemodynamic, ultrasound


How to cite this article:
Zidan D, Baess A. Comparison between femoral vein diameter and inferior vena cava diameter by ultrasound in estimation of central venous pressure in mechanically ventilated patients. Res Opin Anesth Intensive Care 2020;7:100-3

How to cite this URL:
Zidan D, Baess A. Comparison between femoral vein diameter and inferior vena cava diameter by ultrasound in estimation of central venous pressure in mechanically ventilated patients. Res Opin Anesth Intensive Care [serial online] 2020 [cited 2020 Jun 2];7:100-3. Available from: http://www.roaic.eg.net/text.asp?2020/7/1/100/282581


  Introduction Top


A critical component in the management of patient admitted to ICUs is the optimization of hemodynamics, including the adjustment of the intravascular volume, cardiac preload to improve cardiac output, and stroke volume. In spite of the advances in hemodynamic monitoring techniques, central venous pressure (CVP) monitoring remains an effective tool and is used as a circulatory filling parameter. However, its use is limited by many complications such as cardiac arrhythmias, ventricular perforation, pneumothorax, and hemothorax [1].

Instead, bedside ultrasonography is used as a noninvasive method for hemodynamic monitoring, evaluation of inferior vena cava (IVC) diameter by sonography provides an alternative tool for evaluation of intravascular volume. Studies have shown the usefulness of IVC diameter in evaluation of vascular status using collapsibility index and distensibility index in spontaneously and mechanically ventilated patients, respectively. Poor acoustic window is commonly encountered such as in morbid obese patients and in patients with surgical emphysema, leading to difficult imaging of the IVC as compared with more superficial veins.

Femoral vein is a superficial compliant vessel, and images can be easily obtained. A significant correlation between CVP and common iliac vein pressure was reported previously, meaning that the femoral vein could be a noninvasive alternative to the CVP [1].

Our aim was to compare the femoral vein diameter (FVD) and the IVC diameter as surrogates for CVP in mechanically ventilated patients.


  Patients and methods Top


Patient or, if not possible, next of kin was informed of the study, and written informed consent was obtained. We have received the approval of ethical committee in faculty of medicine, Alexandria University. This prospective cohort study was performed at the general and respiratory critical care units of the Alexandria Main University Hospital, Faculty of Medicine.

A total of 100 mechanically ventilated adult patients (≥18 years old) who need hemodynamic monitoring with central venous line insertion at the internal jugular or subclavian veins were included. Patients with intraabdominal hypertension (pressure >12 cmH2O), excessive intraabdominal bowel gas, patients with COPD, patients with mean pulmonary artery pressure over 25 mmHg by echocardiography, and pregnant women were excluded.

During measurement, the patient was in supine position. The CVP was uniformly measured at end expiration, with the pressure transducer having been zeroed at the level of mid axillary line. Patients were ventilated on mandatory volume control at 12–14 breath/min with 8–10 ml/kg tidal volume and positive end-expiratory pressure (PEEP) of 5 cmH2O [2].

Simultaneously, IVC image was obtained using General Electric ultrasound machine and 3.5-MHz convex probe. The transducer is placed in a vertical plane in the subxiphoid view. The intrahepatic portion of the IVC was visualized as it entered the right atrium. Approximately 3–4 cm from the junction of the IVC and right atrium, the IVC diameter was obtained. Using M mode, the maximum and minimum diameter during inspiration and expiration diameter were recorded, respectively [2].

To get the FVD, we scanned the femoral triangle starting at the inguinal crease using a linear array transducer (5–10 MHZ). FVD was measured just caudal to the saphenofemoral junction. Adequate compression was used to check patency of the vessel and to confirm that the vessel was venous. Measurements were done without regarding the respiratory cycle [3].

Statistical analysis

Data are presented as median with corresponding interquartile range for continuous variables and as frequencies with corresponding percentages for categorical variables. Between-group comparison was done by Mann–Whitney U test for continuous variable and by χ2 test for categorical variables. P value less than 0.05 was considered significant. Data were analyzed by SPSS Statistics 21 (IBM).


  Results Top


We enrolled 100 patients in this study. Their mean age was 56 years, mean CVP was 6 cm H2O, mean IVC diameter during inspiration was 15 cm whereas during expiration was 13.6 cm, and mean FVD was 8.2 cm ([Table 1]).
Table 1 Patient characteristics

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Regarding correlations, there were significant correlations between both CVP and IVC diameter (insp and exp) and FVD.

CVP correlation with FVD was 0.59, IVC diameter during inspiration with FVD was 0.41 and IVC diameter during expiration was 0.42 ([Table 2], [Figure 1],[Figure 2],[Figure 3]).
Table 2 Correlation between central venous pressure, inferior vena cava diameter, and femoral vein diameter

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Figure 1 Scatter plot for the correlation between FVD and CVP.

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Figure 2 Scatter plot for the correlation between FVD and IVC-Insp.

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Figure 3 Scatter plot for the correlation between FVD and IVC-Exp.

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  Discussion Top


In spite of the new era in hemodynamic monitoring, still central venous catheter is used for assessment of intravascular fluid status. Recently bedside ultrasound is an alternative noninvasive method used in intravascular fluid monitoring [2].

Cho et al. [3], concluded that FVD is accurate in CVP assessment when compared with IVC diameter measured by ultrasound and could be useful in case of measurement of IVC diameter. Their results were in concordance with our findings as we found that there is a statistically significant correlation between the measurements of CVP, IVC (insp and exp) and FVD. However, Citilcioglu and colleagues, found no correlation between respiratory variation of IVC diameters measured by ultrasonography and measured CVP readings at the same phases. This disagreement with our results could be explained by their small sample size, as they worked on 11 mechanically ventilated shocked patients in emergency [4].

Malik et al. [5], also concluded that FVD was significantly correlated to CVP readings and it may be used as an alternative noninvasive method for monitoring of the intravascular status in the critically ill patients. Moreover, Kent et al. [6], found that femoral venous collapsibility assessments, may be an acceptable candidates for ‘second-line’ alternative sites to IVC assessment sonographically in the patient in whom imaging of the latter is hindered.

Ciozda et al. [7] concluded that in patients attached to mechanical ventilator, there is nonsignificant correlations between IVC dimension measured by ultrasound and CVP measurements. They attributed this conclusion to the variable PEEP levels applied in mechanically ventilated patients. However, we found opposite results in our study, as there was a statistically significant correlation between CVP and IVC diameter. This disagreement could be explained by the adjusted level of PEEP (5 cmH2O) used in our research. Kircher et al. [8] reported that there is a significant correlation between IVC diameter assessed by sonography and CVP but in spontaneously breathing patients, which was considered as a limitation of their study. Moreover, Ilyas et al. [9] concluded that collapsibility index of IVC can be an alternative method in estimation of intravascular volume in critically ill patients.


  Conclusion Top


FVD can be used as a noninvasive alternative method to assess intravascular volume status.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Boldt J, Lenz M, Kumle B. Volume replacement strategies on ICUs: results from a postal survey. Intensive Care Med 1998; 24:147–151.  Back to cited text no. 1
    
2.
Citilcioglu S, Sebe A, Oguzhan A, Icme F, Avci A, Gulen A. The relationship between inferior vena cava diameter measured by bedside ultrasonography and central venous pressure value. Pak J Med Sci 2014; 30:310–316.  Back to cited text no. 2
    
3.
Cho R, Williams D, Leatherman J. Measurement of femoral vein diameter by ultrasound to estimate central venous pressure. Annals ATS 2015; 10:1–15.  Back to cited text no. 3
    
4.
Citilcioglu S, Sebe A, Ay M, Icme F, Avci A, Gulen M et al. The relationship between inferior vena cava diameter measured by bedside ultrasonography and central venous pressure value. Pak J Med Sci 2014; 30:2.  Back to cited text no. 4
    
5.
Malik A, Akhtar A, Saadat S, Mansoor S. Predicting central venous pressure by measuring femoral venous diameter using ultrasonography. Cureus 2016; 8:e893.  Back to cited text no. 5
    
6.
Kent A, Patil P, Davila V, Bailey J, Jones C, Evans D et al. Sonographic evaluation of intravascular volume status: can internal jugular or femoral vein collapsibility be used in the absence of IVC visualization? Ann Thorac Med 2015; 10:44–49.  Back to cited text no. 6
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7.
Ciozda W, Kedan I, Kehl D, Zimmer R, Khandwalla R, Kimchi A. The efficacy of sonographic measurement of inferior vena cava diameter as an estimate of central venous pressure. Cardiovasc Ultrasound 2016; 14:33.  Back to cited text no. 7
    
8.
Kircher J, Himelman B, Schiller B. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol 1990; 66:493–496.  Back to cited text no. 8
    
9.
. Ilyas A, Ishtiaq W, Assad S, Ghazanfar H, Mansoor S, Haris M et al. Correlation of IVC diameter and collapsibility index with central venous pressure in the assessment of intravascular volume in critically ill patients. Cureus 2017; 9:e1025.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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