
 Goals of volume management are to accurately assess intravascular and extravascular volume and predict response to volume administration, vasopressor support, or volume removal.
 Data are reviewed that support the following:
 1) Dynamic parameters reliably guide volume administration and may improve clinical outcomes compared to static parameters, but some are invasive or only validated with mechanical ventilation without spontaneous breathing.
 2) Ultrasound visualization of inferior vena cava (IVC) diameter variations with respiration reliably assesses intravascular volume and predicts volume responsiveness.
 3) Although physiology of IVC respiratory variations differs with mechanical ventilation and spontaneous breathing, IVC collapsibility index (CI) and distensibility index are interconvertible.
 4) Prediction of volume responsiveness by IVC CI is comparable for mechanical ventilation and spontaneous breathing patients.
 5) Respiratory variations of subclavian/proximal axillary and internal jugular veins by ultrasound are alternative sites, with comparable reliability.
 6) Data support clinical applicability of IVC CI to predict hypotension with anesthesia, guide ultrafiltration goals, predict dry weight, predict intra-dialytic hypotension, and assess acute decompensated heart failure.
 7) IVC ultrasound may complement ultrasound of heart, lungs, and abdominal organs for venous congestion, for assessing and managing volume overload and deresuscitation, renal failure, and shock.
 8) IVC ultrasound has limitations including inadequate visualization.
 Ultrasound data should always be interpreted in clinical context. Additional studies are required to further assess and validate the role of bedside ultrasonography in clinical care.

/pdf/inferior-vena-cava-ultrasound-and-other-techniques-for-wbdki529.pdf

Inferior vena cava ultrasound and other techniques for assessment of intravascular and extravascular volume: an update

Prevention of hypotension after induction of general anesthesia using point-of-care ultrasound to guide fluid management: a randomized controlled trial.

Postinduction hypotension (PIH) is closely associated with postoperative adverse outcomes. Preoperative hypovolemia is a key risk factor, and many parameters are available from ultrasound to detect hypovolemia, but the accuracy of PIH from ultrasound remains unclear. This systematic review and meta-analysis aimed to evaluate the commonly used measurements from ultrasound to predict PIH. We searched the PubMed, Cochrane Library, Embase, CNKI, and Web of Science databases from their inception to December 2023. Thirty-six studies were included for quantitative analysis. The pooled sensitivities for the inferior vena cava collapsibility index (IVC-CI), maximum inferior vena cava diameter (DIVCmax), minimum inferior vena cava diameter (DIVCmin), and carotid artery corrected flow time (FTc) were 0.73 (95% CI = 0.65, 0.79), 0.66 (95% CI = 0.54, 0.77), 0.74 (95% CI = 0.60, 0.85), and 0.81 (95% CI = 0.72, 0.88). The pooled specificities for the IVC-CI, DIVCmax, DIVCmin, and carotid artery FTc were 0.82 (95% CI = 0.75, 0.87), 0.75 (95% CI = 0.66, 0.82), 0.76 (95% CI = 0.65, 0.84), and 0.87 (95% CI = 0.77, 0.93). The AUC for the IVC-CI, DIVCmax, DIVCmin, and carotid artery FTc were 0.84 (95% CI = 0.81, 0.87), 0.77 (95% CI = 0.73, 0.81), 0.82 (95% CI = 0.78, 0.85), and 0.91 (95% CI = 0.88, 0.93). Our study demonstrated that ultrasound indices are reliable predictors for PIH. The carotid artery FTc is probably the optimal ultrasound measurement for identifying patients who will develop PIH in our study.

Preoperative Ultrasound for the Prediction of Postinduction Hypotension: A Systematic Review and Meta-Analysis

Abstract Introduction Obesity increases the risk of morbidity and mortality during surgical procedures. Goal-directed fluid therapy (GDFT) is a new concept for perioperative fluid management that has been shown to improve patient prognosis. This study aimed to investigate the role of the Pleth Variability Index (PVI), systolic pressure variation (SPV), and pulse pressure variation (PPV) in maintaining tissue perfusion and renal function during GDFT management in patients undergoing laparoscopic sleeve gastrectomy (LSG). Materials and Methods Two hundred ten patients were enrolled in our prospective randomized controlled clinical trial. Demographic data, hemodynamic parameters, biochemical parameters, the amount of crystalloid and colloid fluid administered intraoperatively, and the technique of goal-directed fluid management used were recorded. Patients were randomly divided into three groups: PVI ( n = 70), PPV ( n = 70), and SPV ( n = 70), according to the technique of goal-directed fluid management. Postoperative nausea and vomiting, time of return of bowel movement, and hospital stay duration were recorded. Results There was no statistically significant difference between the number of crystalloids administered in all three groups. However, the amount of colloid administered was statistically significantly lower in the SPV group than in the PVI group, and there was no significant difference in the other groups. Statistically, there was no significant difference between the groups in plasma lactate, blood urea, and creatinine levels. Conclusion In LSG, dynamic measurement techniques such as PVI, SPV, and PPV can be used in patients with morbid obesity without causing intraoperative and postoperative complications. PVI may be preferred over other invasive methods because it is noninvasive. Graphical abstract 

Comparison of Dynamic Measures in Intraoperative Goal-Directed Fluid Therapy of Patients with Morbid Obesity Undergoing Laparoscopic Sleeve Gastrectomy.


 
 Short-term hypotension after general anaesthesia can negatively impact surgical outcomes. This study compared the predictive potential of the pleth variability index (PVI), pulse pressure variability (PPV), and perfusion index (PI) for anaesthesia-induced hypotension. This study’s primary objective was to evaluate the predictive potential of PI, PVI, and PPV for hypotension.
 
 
 
 This observational study included 140 adult patients undergoing major abdominal surgery under general anaesthesia. Mean arterial pressure, heart rate, PVI, PPV, and PI were collected at 1-min intervals up to 20 min post anaesthesia induction. Hypotension was assessed at 5-min and 15-min intervals. Receiver operating characteristic (ROC) curves were plotted to determine the diagnostic performance and best cut-off for continuous variables in predicting a dichotomous outcome. Statistical significance was kept at P < 0.05.
 
 
 
 Hypotension prevalence within 5 and 15 min of anaesthesia induction was 36.4% and 45%, respectively. A PI cut-off of <3.5 had an area under the ROC curve (AUROC) of 0.647 (P = 0.004) for a 5-min hypotension prediction. The PVI’s AUROC was 0.717 (P = 0.001) at cut-off >11.5, while PPV’s AUROC was 0.742 (P = 0.001) at cut-off >12.5. At 15 min, PVI’s AUROC was 0.615 (95% confidence interval 0.521–0.708, P = 0.020), with 54.9% positive predictive value and 65.2% negative predictive value.
 
 
 
 PVI, PPV, and PI predicted hypotension within 5 min after general anaesthesia induction. PVI had comparatively higher accuracy, sensitivity, specificity, and positive predictive value than PI and PPV when predicting hypotension at 15 min.


Comparison between perfusion index, pleth variability index, and pulse pressure variability for prediction of hypotension during major abdominal surgery under general anaesthesia: A prospective observational study

http://www.cell.com/article/S2405844022024963/pdf

Clinical utility of ultrasonography, pulse oximetry and arterial line derived hemodynamic parameters for predicting post-induction hypotension in patients undergoing elective craniotomy for excision of brain tumors - A prospective observational study

BACKGROUND
Goal directed fluid therapy (GDFT) may be a rational approach to adopt in neurosurgical patients, in whom intravascular volume optimization is of utmost importance. Most of the parameters used to guide GDFT are derived invasively. We postulated that the total volume of intraoperative intravenous fluid administered during elective craniotomy for supratentorial brain tumours would be comparable between two groups receiving GDFT guided either by the non-invasively derived plethysmography variability index (PVI) or by stroke volume variation (SVV).


METHODS
60 ASA category 1, 2 and 3 patients between 18 and 70 years of age were randomized to receive intraoperative fluid guided either by SVV (SVV group; n = 31) or PVI (PVI group; n = 29). The total volume of fluid administered intraoperatively was recorded. Serum creatinine was measured before the surgery, at the end of the surgery, 24 h after surgery and on the fifth post-operative day. Arterial cannulation was performed before induction in all patients. Serum lactate was measured before induction, once in 2 h intraoperatively, at the end of the surgery and 24 h after the surgery. Brain relaxation score was assessed by the surgeon during dural opening and dural closure. Patients were followed up till discharge or death. The duration of mechanical ventilation and the duration of hospital stay was noted for all patients.


RESULTS
The volume of fluid given intraoperatively was significantly higher in the SVV group (p = 0.005). The two groups were comparable with respect to serum lactate and serum creatinine measured at pre-determined time intervals. Brain relaxation score was also comparable between the groups. SVV and PVI displayed moderate to strong correlation intraoperatively. The duration of mechanical ventilation and the length of the hospital stay were comparable between the two groups.


CONCLUSIONS
PVI and SVV are equally effective in guiding GDFT in adults undergoing elective craniotomy for supratentorial brain tumours.

Comparison of two techniques of goal directed fluid therapy in elective neurosurgical patients - a randomized controlled study.

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Clinical utility of ultrasonography, pulse oximetry and arterial line derived hemodynamic parameters for predicting post-induction hypotension in patients undergoing elective craniotomy for excision of brain tumors - A prospective observational study

Comparison of two techniques of goal directed fluid therapy in elective neurosurgical patients - a randomized controlled study.