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Review article

The use of preoperative inferior vena cava ultrasound to predict anaesthesia-induced hypotension: a systematic review

Sumit Roy Chowdhury
1
,
Priyankar Kumar Datta
2
,
Souvik Maitra
2
,
Dimple Rawat
3
,
Dalim Kumar Baidya
2
,
Avishek Roy
2
,
Sayan Nath
2

1.
Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
2.
Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
3.
Clinical Epidemiology Unit, All India Institute of Medical Sciences, New Delhi, India
Anaesthesiol Intensive Ther 2023; 55, 1: 18–31
Online publish date: 2023/03/02
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Intraoperative hypotension after induction or initiation of anaesthesia is a common complication in clinical practice. It has been associated with poor patient outcomes including increased peri-operative morbidity and even mortality [1]. Some special patient populations, such as the elderly and pregnant women undergoing caesarean section, are particularly prone to developing significant anaesthesia-induced hypotension (AIH) due to their unique physiological characteristics. Hypotension after induction of general anaesthesia (PIH, post- induction hypotension) or administration of spinal anaesthesia (PSH, post-spinal hypotension) is common and profound in patients with intravascular volume depletion [2]. It may result in nausea, vomiting, aspiration, dizziness, syncope, acute kidney injury and even cardiac dysrhythmias [3].

Preoperative intravascular volume optimization may help avoid hypotension after induction of anaesthesia. On the other hand, excessive intravascular volume loading might result in side effects of volume overload such as pulmonary oedema, congestive cardiac failure, renal dysfunction, and poor surgical outcomes. Hence, it would be of great value for anaesthesiologists to have a reliable tool for assessing intra-vascular volume status that can accurately predict the occurrence of AIH, so that preoperative fluid administration and optimization can be instituted for only those who will benefit from it.

There is no consensus yet on the optimal method for the assessment of preoperative intravascular volume status and fluid responsiveness [4]. Various non-invasive modalities such as transthoracic echocardiography (TTE), transthoracic bioimpedance, and the passive leg raising test (PLRT) have been investigated as tools for detecting intravascular volume depletion [4, 5]. Ultrasound (US) imaging of the inferior vena cava (IVC) is being used as a tool for assessing cardiac preload or intravascular volume status and has gained popularity because of its relative ease of use, feasibility, reproducibility, non-invasive nature, and cost-effectiveness. Respiratory phasic variation of the IVC diameter measured as a percentage decrease of IVC diameter at inspiration taking the expiratory diameter as baseline in a spontaneously breathing patient is known as the IVC collapsibility index (IVCCI). For long, it has been considered a reliable predictor of volume status and fluid responsiveness in critically ill patients until very recently a review questioned its utility [6]. Although several recent studies have assessed the role of IVCUS in predicting either PSH or PIH, there is no systematic review on this topic that summates the evidence. Whether IVCUS can be used to predict intraoperative hypotension remains an unanswered question. Therefore, the objective of this systematic review is to assess the role of IVCUS- derived parameters to predict PSH or PIH.

METHODS

This systematic review was conducted as per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and the protocol for this review was prospectively regi-stered [7]. Institute ethics committee approval was waived and informed consent from patients was not applicable due to the nature of the article.

Search strategy

Using a pre-defined search strategy #11 “((Inferior vena cava collapsibility index) OR (Inferior vena cava ultrasound) OR (IVC collapsibility index) OR (IVCCI) OR (Inferior vena cava diameter) OR (IVC variability) OR (IVC distensibility) OR (IVC collapsibility) OR (IVC spontaneous breathing) AND (Hypotension))” a literature search was conducted on the search engine PubMed from inception to 18.06.2022 (3:00 PM), along with a meticulous manual search.

  1. Inferior vena cava collapsibility index

  2. Inferior vena cava ultrasound

  3. IVC collapsibility index

  4. IVCCI

  5. Inferior vena cava diameter

  6. IVC variability

  7. IVC distensibility

  8. IVC collapsibility

  9. IVC spontaneous breathing

  10. Hypotension

  11. #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 AND #10: (N=276)

Inclusion criteria

Observational studies and randomized control trials assessing the role of pre-operative IVCUS- derived parameters and PSH or PIH in adult patients were included in the review.

Exclusion criteria

Studies involving paediatric patients, those not published in the English language, and studies of which full texts were unavailable or in pre-proof stage were excluded from the review. No communication was made with the authors for the full text if it was not available.

Study selection

Initial screening of title and abstracts of the search results was followed by full-text screening of selected articles by SRC, PKD, and DR. In case of any disagreement regarding the inclusion of an article, the opinion of SM or DKB was sought. The study selection process for this review is depicted in Figure 1. Turconi et al. [8] investigated 55 high risk cardiac patients undergoing vascular surgery under GA and found IVCCI as a poor predictor of intraoperative hypotension. Aissaoui et al. [9] also found IVCCI > 42% as a poor predictor of hypotension after GA induction in 64 patients aged more than fifty years undergoing elective abdominal surgery. These two studies were excluded from our review as the full text of these studies were not available, but wherever applicable we have presented the data available from the abstract of these two studies.

FIGURE 1

Study flow diagram

/f/fulltexts/AIT/50184/AIT-55-50184-g001_min.jpg

Data extraction

Relevant data extraction was performed by SRC, SN and DR with respect to the study population, sample size, incidence of PSH or PIH, type of surgery, IVCUS technique, definition of PSH or PIH, drugs used for spinal anaesthesia (SA) or induction of general anaesthesia (GA), IVCCI cut-offs to predict PSH or PIH with sensitivity and specificity, additional parameters derived by IVCUS using the PICO (population, intervention, control, and outcomes) framework.

Methodological quality of study

Risk of bias and applicability concerns summary

Risk of bias at the study level was assessed as per QUADAS 2 methodology and it had four key domains: patient selection; index test; reference standard; flow and timing [10].

Effect measures

Primary outcome: Role of pre-operative IVCCI to predict PSH or PIH.

Secondary outcome: Role of other pre-operative IVCUS derived parameters to predict PSH or PIH.

Risk of bias of individual studies was independently assessed by two review authors (SM & DKB) and reported in Figures 2 and 3 (green – low risk, yellow – unclear risk, red – high risk).

FIGURE 2

Risk of bias and applicability concerns summary: review authors’ judgements about each domain for each included study (green – low risk, yellow – unclear risk, red – high risk)

/f/fulltexts/AIT/50184/AIT-55-50184-g002_min.jpg
FIGURE 3

Risk of bias and applicability concerns graph: review authors’ judgements about each domain presented as percentages across included studies

/f/fulltexts/AIT/50184/AIT-55-50184-g003_min.jpg

Due to extreme heterogeneity of data, sensitivity analysis or meta-analysis was not done.

RESULTS

Study characteristics

Patient population and type of surgery

The role of IVCUS to predict PSH was assessed in 15 studies [1125]. Among them 4 prospective observational studies evaluated PSH in a parturient undergoing caesarean section [1114]. The age of the parturient varied between 18 and 40 years.

In studies among non-parturients, 4 studies were randomized controlled trials [1517, 25] and the rest were observational studies [1824]. These studies were conducted in procedures such as hernia and hydrocele [16], orthopaedic lower limb surgery [15, 2022], and various other operations performed under spinal anaesthesia. These studies included adult patients between 18 and 75 years old [19]. Two studies recruited only elderly patients [22, 23]. Among the studies done in non-parturient patients, 8 studies excluded American Society of Anaesthesiology (ASA) class ≥ III [1521, 24], whereas 1 study each included ASA class I–III [25], ASA class II–III [22]and ASA class I–IV [23] patients.

Six observational studies evaluated the role of preoperative IVCUS for PIH in non-pregnant patients undergoing elective surgery under GA [2631]. All these studies were done in adult patients. The ASA class of included patients was I–II in three studies [27, 28, 31], I–III in one study [29], II–III in one study [30], while one study did not mention the ASA class of the patients [26].

Drugs used

The local anaesthetic drugs used for SA were both plain and hyperbaric bupivacaine, isobaric ropivacaine and levobupivacaine [1125]. The most common adjuvant drug for SA was fentanyl. In one study 60 mg of buprenorphine was used [15]. For GA, 5 studies used propofol [2628, 30, 31]. One study used etomidate [29]. Fentanyl was co-admini-stered at induction in all but one study [26].

IVC ultrasound technique

Low frequency curvilinear [11, 12, 14, 15, 19, 21, 23, 24, 29] or phased array [13, 22, 29] US transducers with the frequency range of 1–8 MHz were used for IVCUS in all these studies. IVC diameter was obtained at a point ranging between 0.5 cm [27] and 5 cm [12] from the IVC-right atrium (RA) junction. In some studies, the IVC diameters were obtained at points ranging between just proximal to [22], to 2 cm distal [20, 21, 30] to the junction of the hepatic vein and IVC.

Definition of hypotension

The definition of PSH varied widely among different studies: fall in SBP > 20% [11, 13], fall in SBP > 25% [15, 16, 25], fall in SBP > 30% [20], absolute fall in SBP > 50 mmHg [25], SBP value < 90 mmHg [24], SBP < 80 mmHg [25], fall in MAP > 20% [12, 14, 18], fall in MAP > 30% [17, 23], MAP < 65 mmHg [12, 14, 22], MAP < 60 mmHg [1517, 24, 25], and fall in BP (unspecified) > 30% [19, 21]. The timeframe for PSH was defined as within 15 minutes after spinal drug administration in 3 studies [12, 18, 20], within 30 minutes in 2 studies [19, 23], within 45 minutes in one study [21], and until the end of surgery in two studies [11, 22]. The rest of the studies did not clearly define any timeframe in the definition of PSH.

The definition of PIH also varied widely: SBP < 90 mmHg or use of vasopressors within 21 minutes of propofol administration [26], MAP < 65 mmHg or fall in MAP > 30% [30], MAP < 65 mmHg or fall in MAP > 30% within 10 minutes of propofol administration [28], MAP < 60 mmHg or use of vasopressors until 15 minutes after GA induction [31], SBP < 90 mmHg or fall in SBP ≥ 30% [27], and fall in MAP > 30% or MAP < 60 mmHg until 10 minutes of tracheal intubation [29].

Incidence of hypotension

Incidence of PSH varied from 42.8% [13] to 76% [11] in pregnant patients undergoing caesarean section [11, 13] and from 18.3% to 45% in non- pregnant patients [17, 18, 21]. Incidence of post- induction hypotension varied from 19.3% in the study by Mohammed et al. [28] to 70% in the study by Fiza et al. [30].

Predictability of hypotension

IVCCI as a predictor of PSH had the highest sensitivity of 84.6% and the highest specificity of 93.1% in the same study (at a cut-off > 33%) [14]. The lowest sensitivity reported was 58.8% at a cut-off > 21.15% and the lowest specificity was 23.5% at a cut-off > 20.4% [12, 18].

IVCCI as predictor of PIH had the highest sensitivity of 86.67% and the highest specificity of 94.29% in the same study at a cut-off > 43% [31]. The lowest reported sensitivity was 45.5% and the lowest reported specificity was 77.27% both at a cut-off > 50% [26, 27].

Among the parameters other than IVCCI which were obtained from IVCUS, the IVC diameters and IVC peak velocity could not reliably predict PSH in 6 studies [1113, 18, 20, 21]. However, one study found the minimum IVC diameter to be significantly lower in patients who developed subsequent hypotension [14]. In the study by Aslan et al. [23] the expiratory IVC diameter < 1.8 cm could predict PSH with an odds of 3.289. In another study, dIVCmax- to-IVCCI ratio, where dIVCmax was the maximum dia-meter of IVC at expiration, was a reliable predictor of PSH in elderly patients aged more than 70 years [22]. The maximum and minimum IVC dia-meters could not predict PIH in one study [28], but in another study the maximum IVC diameter of < 1.8 cm could predict PIH with moderate sensitivity (73.8%) and specificity (70.8%) [29]. The population charac-teristics, different definitions of anaesthesia- induced hypotension and the drugs used in different studies are presented in Table 1. Different me-thods of IVCUS and the important findings of the studies are presented in Table 2. The data collected from the abstract of the two studies which were excluded due to non-availability of the full text are also included in Table 1 and Table 2, as both these studies had the objective of our interest.

TABLE 1

Population characteristics, definition of anaesthesia-induced hypotension and drugs used in included studies

S. noAuthor and yearStudy type, sample sizePopulationDefinition of intraoperative hypotensionIncidence
of hypotension
Drugs used and dosage
1Spinal anaesthesiaPregnant patientsYao et al.,
2021 [13]
Observational
56
Age 18–40 years parturient undergoing caesarean sectionFall in SBP > 20% from
the baseline
42.8%0.75% isobaric ropivacaine (12 mg) with fentanyl (10 mg) in spinal; 27-G Whitacre needle
2Kundra et al.,
2014 [11]
Observational
32
Age 20–30 years parturient undergoing caesarean sectionFall in SBP > 20% by the end of surgery76.0%9 mg (0.5%) bupivacaine in spinal
3Singh et al.,
2019 [12]
Observational
40
Parturient undergoing caesarean section20% fall in MAP or MAP
< 65 mmHg within 15 minutes
57.5%8 mg (0.5%) heavy bupivacaine with 20 mg fentanyl in spinal;
25G Sprotte needle
4Elbadry et al.,
2021 [14]
Observational
55
25–35 years parturient undergoing caesarean sectionFall in MAP > 20% from baseline or MAP < 65 mmHg47.3%12.5 mg heavy bupivacaine with 20 mg fentanyl; 25G spinal needle
5Non-pregnant patientsDevi et al.,
2021 [15]
RCT
100
18–60 years old, ASA class I–II patients undergoing orthopaedic lower limb surgery; one group received IVCUS guided fluid therapy (CI) and the other group did not undergo IVCUS (NCI)25% fall from baseline SBP
or MAP < 60 mm Hg
28.0% overall; 18.0% in CI group and 38.0% in NCI group12–15 mg heavy bupivacaine with 60 mg (0.2 mL) buprenorphine in spinal; 25G Quincke’s needle
6Ayyanagouda et al.,
2020 [16]
RCT
80
18–60 years, ASA class I–II patients undergoing inguinal hernia and hydrocele surgery. Randomised to two groups – IVCUS guided fluid therapy (group A) and no IVCUS (group B)25% fall in baseline SBP
or MAP < 60 mm Hg
35.0% in Group A, 20.0% in group B15–18 mg 0.5% heavy bupivacaine; 25G Quincke’s needle
7Ceruti et al.,
2018 [25]
RCT
160
18–65 year, ASA class I–III patients non-cardiac, non- obstetric surgery under spinal anaesthesia; one group received IVCUS guided fluid therapy (group IVCUS) and the other group did not undergo IVCUS (group C)Fall in SBP > 50 mmHg or 25% of baseline, absolute SBP < 80 mmHg, MAP < 60mmHg, 30% fall in MAP for more than 30 seconds35.0% overall, 27.5% in IVCUS and 42.5% in other group12–18 mg (0.5%) heavy bupivacaine with 27G pencil point spinal needle
8Ni et al.,
2022 [17]
RCT
90
18–65 years, ASA class I–II patients undergoing non-cardiovascular, non-obstetric surgery under spinal anaesthesia, Randomized to two groups – IVCCUS guided fluid therapy (IVCCI group) and standard fluid therapy without IVCCUS (Standard group)Fall in MAP > 20% within 15 minutes after spinal anaesthesia23.8%;
31.7% in standard group and 15.3% in IVCCUS group
12–15 mg 0.5% plain bupivacaine; 25G Quincke needle
9Chowdhury et al., 2022 [18]Observational
50
Age 18–65 years, ASA class I–II patients undergoing elective infra-umbilical surgery30% fall from baseline BP (not clearly mentioned SBP/DBP/MAP) till 30 minutes34.0%12.5 mg 0.5% heavy bupivacaine with 25 mg fentanyl in spinal
10Roy et al.,
2021 [19]
Observational
129
Age 18–75 years, ASA I–II patients undergoing elective surgery under spinal anaesthesiaFall in SBP > 30% from baseline measured until 15 minutes after spinal anaesthesia19.4%12.5–15 mg 0.5% heavy bupivacaine in spinal;
25 or 27G Quincke’s needle
11Spinal anaesthesiaJaremko et al., 2019 [20]Observational
60
Age > 18 years , ASA class I–II patients undergoing knee joint replacement surgeryFall in SBP more than or equal
to 25% or MAP < 65 mmHg for 30 seconds until the end of surgery
18.3%15–17 mg levobupivacaine
in spinal
12Saranteas et al., 2019 [22]Observational
70
Elderly patients > 70 years; ASA class II–III, undergoing lower limb surgery under spinal anaesthesiaFall in MAP > 30% from baseline within 30 minutes after spinal anaesthesia41.0%12–18 mg 0.75% plain ropivacaine in spinal; 22 or 25 G pencil point spinal needle; additionally to facilitate lateral positioning for spinal anaesthesia US guided PNBs were performed; 10–20 mg propofol administered before PNBs
13Aslan et al.,
2021 [23]
Observational
73
Age > 65 years, ASA I–IV patients undergoing surgery under spinal anaesthesiaFall in BP > 30% from baseline (SBP/DBP/MAP not mentioned) measured for 45 minutes38.4%12.5 mg 0.5% bupivacaine;
25G Quincke needle
14Mačiulienė et al., 2018 [21]Observational
60
Age ≥ 18 years, ASA class I-II patients undergoing knee joint replacement surgeryFall in MAP > 30% of the baseline value or any MAP < 60 mmHg; severe hypotension defined as MAP < 55 mm Hg18.3%15–17 mg levobupivacaine
in spinal; 27-G spinal pencil
type needle
15Salama et al.,
2019 [24]
Observational
100
Age > 18 years, ASA class I–II patients undergoing elective surgery under spinal anaesthesiaSBP < 90 mmHg or fall in SBP > 30% of the baseline value or any MAP < 60 mmHg45.0%12 to 15 mg 0.5% hyperbaric bupivacaine in spinal; 26-gauge Whitacre needle
16General anaesthesiaTurconi et al.,
2022 [8]
(only abstract available)**
Observational
55
High risk cardiac patients undergoing vascular surgery under general anaesthesiaThree definitions of intraoperative hypotension were used: systolic blood pressure (SBP) less than
100 mmHg, mean arterial pressure (MAP) less than 60 mmHg, and a decrease in MAP greater than or equal to 30% compared to baseline
NANA
17Aissaoui et al.,
2022 [9]
(pre-proof, only abstract available)**
Observational
64
Age > 50 years patients undergoing elective abdominal surgery under GASBP < 90 mmHg or MAP < 65 mmHg or fall in MAP > 30% from pre-induction level51.0%NA
18Au et al.,
2016 [26]
Observational
40
Age > 18 years, patients undergoing elective surgical procedures under general anaesthesiaSBP < 90 mm Hg or use
of vasopressors within 21 minutes after administration of propofol
45.0%Propofol dose at the discretion
of the anaesthesiologist;
mean dose: 2.4 mg kg–1;
no mention of fentanyl or MR
19General anaesthesiaFiza et al.,
2020 [30]
Observational
63
Adult patients, ASA class II–III undergoing non-cardiac surgery under GAMAP < 65 mmHg or fall in MAP
> 30% from preoperative value
70.0% according to definition by MAP
< 65 mmHg, 68.0% according to fall in MAP, 49.0% for both definitions
Mean (SD) propofol dose
1.86 mg kg–1 (0.34 mg kg–1) with mean fentanyl 125 mg at general anaesthesia induction; 93.7% patients received fentanyl; 73% patients received midazolam 1–2 mg before induction;
no mention of MR
20Purushothaman et al., 2020 [31]Observational
50
Age > 18 years, ASA classes I and II patients undergoing surgery under general anaesthesia with propofol
as induction agent
MAP <60 mmHg or use of rescue vasopressors till 15 minutes after GA induction30.0%Midazolam 0.05–0.1 mg kg–1, propofol 1–2 mg kg–1 with fentanyl 2–3 mg kg–1, atracurium as muscle relaxant 0.5 mg kg–1
21Mohammed et al., 2021 [28]Observational
110
Age 18 to 50 years, ASA class I and II patients undergoing surgery under GA with propofol for inductionMAP < 65 mmHg or fall in MAP > 30% from baseline to 10 minutes from GA induction;
significant hypotension MAP < 55 mm Hg or fall in BP > 40% or hypotension duration ≥ 2 min
19.3%Midazolam, fentanyl, propofol, MRs (not specified) dose at the discretion of anaesthesiologist
22Szabo et al.,
2019 [27]
Observational
83
Age > 18 years, ASA class I–II patients undergoing elective general surgery under general anaesthesia with propofol inductionSBP < 90 mmHg or ≥ 30% drop of SBP from the baseline34.1% in patients with IVCCI > 50% and 24.2% in patients with IVCCI < 50%1.5–2 mg kg–1 propofol with 1-2 mg kg–1 fentanyl and rocuronium or cis-atracurium
23Zhang et al.,
2016 [29]
Observational
90
Adult patients, ASA class I to III patients undergoing elective surgery under general anaesthesia with etomidate for inductionFall in MAP > 30% from baseline or MAP less than 60 mmHg until 10 minutes after tracheal intubation46.7%0.01 mg kg–1 midazolam, 0.3 mg kg–1 etomidate with 2–3 mg kg–1 fentanyl with cis-atracurium or rocuronium

[i] IVCUS – inferior vena cava ultrasound, RCT – randomised control trial, ASA – American Society of Anesthesiologists, SBP – systolic blood pressure, MAP – mean arterial pressure, DBP – diastolic blood pressure, PNB – peripheral nerve block, IVCCI – inferior vena cava collapsibility index

TABLE 2

Method of IVC US and important findings of included studies

S.
no
Author and yearMethod of IVCUSParameters derived by IVCUSDiagnostic accuracy of IVCCIAUROC IVCCIDiagnostic accuracy of other parameters derived from IVC US
1Spinal anaesthesiaPregnant patientsYao et al., 2021 [13]Cardiac probe (5–1 MHz); subxiphoid view 2–3 cm from right atrium, anteroposterior diameter and peak velocity of IVC (supine position), IVCCI not seen;
measurements taken at end-expiration
AP diameter (maximum and minimum) and peak velocity of IVCNAAP diameter and peak velocity of IVC failed to predict PSH
2Kundra et al., 2014 [11]3–5-MHz curvilinear probe, checked in 3 different positions – supine, wedged recumbent and left lateral;
measurements taken at end-expiration and end-inspiration at all positions
IVC diameter (maximum and minimum) and IVCCIIVCCI > 13.6% in recumbent with wedge position predicts PSH with a positive predictive value of 86%NAEnd expiratory IVC diameter was not a reliable predictor of PSH
3Singh et al., 2019 [12]Curvilinear 3.5–5 MHz probe, subcostal view, supine position with and without wedge, 3–5 cm distal to RA, just proximal to IVC and hepatic vein junction;
measurements taken at end-expiration and end-inspiration at both positions
IVC diameter (maximum and minimum) and IVCCIIVCCI > 25.64% with 60.9% sensitivity and 35.5% specificity for to predict PSH for supine with wedge position; IVCCI > 20.4% with 69.6% sensitivity and 23.5% specificity for non-wedged position0.46 (wedged position);
0.38 (without wedge)
Maximum and minimum IVC diameter could not predict PSH
4Elbadry et al., 2021 [14]Curvilinear USG probe (1–5 MHz, 21 mm), 3–4 cm away from RA just distal to the hepatic vein; after expiration and inspirationIVC diameter (maximum and minimum) and IVCCI
IVCCI > 33% can predict PSH with 84.6% sensitivity and 93.1% specificity0.95Minimum IVC diameter significantly lower in hypotensive group
5Non-pregnant patientsDevi et al., 2021 [15]Curvilinear probe of 2–5 MHz, subcostal view, 2–3 cm from RA;
measurements taken at maximum end-expiration and at end-inspiration
IVCCINo correlation between IVCCI cut-off 40% and PSHNA
6Ayyanagouda et al., 2020 [16]Curvilinear probe 1–8 MHz, subcostal view, 2 cm from RA; measurements taken in spontaneously breathing patients
IVCCI
NANo correlation between IVCCI > 36% and baseline MAP
7Ceruti et al., 2018 [25]3S-RS probe, 4 MHz, subcostal view 4 cm from right atrium;
measurements taken in spontaneously breathing patients at inspiration and expiration
IVCCISlight correlation (r2 = –0.16) between IVCCI > 36% and reduction of MAP after spinal anaesthesiaNA
8Chowdhury et al.,
2022 [18]
2–5 MHz probe, supine position, 1cm distal to the joining of hepatic vein and IVC;
measurements taken during breathing without deep inhalation at 12-15 breaths per minute
IVC diameters (maximum and minimum), IVCmax/IVCCIIVCCI > 21.15% predicts PSH with 58.8% sensitivity, 69.7% specificity0.6No correlation between maximum and minimum IVC diameter and PSH;
IVCmax/IVCCI > 60 predicted PSH with 58.8% sensitivity and 54.5% specificity
9Spinal anaesthesiaRoy et al., 2021 [19]Curvilinear probe 3.5-5 MHz, subxiphoid view, 2-3 cm distal to IVC-RA junction;
measurements taken both at expiration and inspiration
IVCCINon-significant correlation between IVCCI and PSH (r2 = 0.025)0.467
10Jaremko et al., 2019 [20]Probe not mentioned; 1–2 cm below the level of hepatic veins; supine position with one leg bent;
measurements taken at breathing rate 16(± 2) [mean(± SD)]
IVC diameters (maximum and minimum) and IVCCIIVCCI could not predict PSH< 0.7Expiratory and inspiratory IVC diameters failed to predict PSH
11Saranteas et al., 2019 [22]2–5 MHz phased array probe, IVC diameters measured just proximal to the entry of hepatic veins;
dIVCmax measured at end-expiration but IVCCI measured at spontaneous quite breathing
IVCCI and dIVCmax/IVCCIIVCCI > 30% predicts PSH with 61% sensitivity and 82% specificity0.77dIVCmax/IVCCI < 43 predicts PSH with 80.5% sensitivity and 93% specificity
12Aslan et al., 2021 [23]Curvilinear probe 2-5MHz, subxiphoid view; supine positionIVC diameter(maximum and minimum) and IVCCI0.77 (for end-expiratory diameter)Expiratory IVC diameter < 1.8 cm can predict PSH with odds of 3.289
13Mačiulienė et al.,
2018 [20]
Curvilinear 2-6 MHz, subcostal view, 1–2 cm below the level of the hepatic vein, supine position with one leg bent;
hypotension and IVCCI were measured at base-line (before SA) and at 4 subsequent time points: 1. Immediately after SA; 2. 15 minutes after SA; 3. 30 minutes after SA; 4. 45 minutes after SA;
measurements taken at normal breathing at 14 ± 2 min-1; [mean(± SD)]
IVC diameter(maximum and minimum) and IVCCIIVCCI > 50%, does not predict PSHIVCCI as predictor of hypotension at:
1. Time point-1: AUROC 0.59
2. Time point-2: AUROC 0.57
3. Time point-3: AUROC 0.44
5. Time point-4: AUROC 0.51
Expiratory and inspiratory IVC diameters and IVCCI failed to predict PSH
14Ni et al., 2022 [17]Subcostal view, 2 to 3 cm distal to RA;
measurements taken at the end of expiration and inspiration during same respiratory cycle
IVC diameter (maximum and minimum) and IVCCIIVCCI > 42% can predict PSH w ith 83.9% sensitivity and 76.3% specificity0.834 (IVCCI cut-off > 42%)Patients with smaller IVC diameter developed PSH more frequently
15Salama et al., 2019 [24]Curvilinear 3.5 to 5 MHz probe, subxiphoid view, 3 to 4 cm distal to RA just distal to IVC-hepatic vein junction;
measurements taken at the end of expiration and inspiration during same respiratory cycle
IVC diameters (maximum and minimum) and IVCCIIVCCI > 44.7% can predict PSH with sensitivity of 84%, a specificity of 77%
and accuracy of 84%
0.86
16Turconi et al., 2022 [8]
(only abstract available)**
NAIVCCI poor predictor of intra-operative hypotension0.62
17Aissaoui et al., 2022 [9]
(pre-proof, only abstract available)**
NAIVCCI > 42% poor predictor
of post-induction hypotension
0.68
18General anaesthesiaAu et al., 2016 [26]Subxiphoid or intercostal window; 2 cm below entry of hepatic veins into IVC; to avoid off-midline measurements M-mode employed in the transverse plane;
measurements taken over one normal respiratory cycle
IVC diameter (maximum and minimum) and IVCCIIVCCI > 50% predicts post induction hypotension with 66.67% sensitivity and 77.27% specificityNAIVCCI ≥ 50% had odds ratio of 6.9 in predicting post induction hypotension
19Fiza et al., 2020 [30]Subcostal view, 2 cm caudal to the hepatic vein-IVC junction;
measurements taken at end-expiration
and end-inspiration
IVC diameter (maximum and minimum) and IVCCI
Higher IVCCI was associated with increased incidence of PIH for each definition separately with odds of 1.05 for each definition;
with both definitions of hypotension taken simultaneously, the IVCCI was not a predictor of hypotension
NA
20Purushothaman et al.,
2020 [31]
Subxiphoid view, 2–3 cm distal to RA;
measurements taken in spontaneously breathing patients
IVC diameter (maximum and minimum) and IVCCIIVCCI of > 43% good predictor of post-induction hypotension with 86.67% sensitivity and 94.29% specificity0.959IVCCI > 50% had 53.33% sensitivity and specificity of 100%
21Mohammed et al., 2021 [28]
2.5–5 MHz phased array probe, subcostal view, 2–3 cm from RA;
readings were taken during a single spontaneous breathing cycle
IVC diameter (maximum and minimum) and IVCCIIVCCI ≥ 46% had 47 to 59% sensitivity and 48 to 50% specificity for hypotension;
0.46 (significant hypotension)
0.51 (post induction hypotension)
dIVCmin cut-off 0.73 sensitivity 47% to 53% and specificity 50%
dIVCmax ≥ 1.42 cm sensitivity 47% to 53% and specificity 51 to 53%
22Szabo et al., 2019 [27]5 MHz probe, subxiphoid view, 0.5–3 cm from the RA; if suboptimal view, trans-hepatic lateral view/intercostal view were taken;
measurements taken during normal breathing in lightly sedated patients
IVC diameter (maximum and minimum) and IVCCIIVCCI > 50% had poor sensitivity of 45.5% but high specificity of 90.0% for PIH0.648
23Zhang et al., 2016 [29]Curved linear phased array probe, subcostal view, 2 to 3 cm distal to RA; medium sweep speed kept;
measurements taken over single breathing cycle
IVCCI; IVCmaxIVCCI cut-off 43%, had sensitivity of 78.6% and a specificity of 91.7% for predicting post induction hypotension; IVCCI 38 to 43% considered as grey zone0.9
grey zone for dIVCmax 1.5 to 2.1 cm
dIVCmax cut off 1.8 cm had a sensitivity of 73.8% and specificity of 70.8% for predicting PIH

[i] IVC – inferior vena cava, IVCUS – inferior vena cava ultrasonography, USG – ultrasonography, IVCCI – inferior vena cava collapsibility index, IVCmax or dIVCmax – maximum IVC diameter, IVCmin – minimum IVC diameter, AUROC – area under receiver operator characteristic curve

Discussion

In this systematic review, we have come across contrasting results from studies using IVCUS for prediction of AIH. Heterogeneity with respect to the patient populations under evaluation, definitions used for hypotension after anaesthesia, IVCUS assessment methods, and cut-off values for IVCUS-derived parameters to predict hypotension precluded pooled meta-analysis. The maximum and minimum reported sensitivity of the IVCCI for predicting PSH was 84.6% and 58.8% respectively, while the maximum and minimum specificities were 93.1% and 23.5% respectively. For the prediction of hypotension after general anaesthesia (GA) induction, the reported ranges of sensitivity and specificity of IVCCI were 86.67% to 45.5% and 94.29% to 77.27%, respectively.

The cause of this wide disparity in results is multi-factorial. Firstly, there is a lack of consensus on the definition of hypotension under anaesthesia. Klöhr et al. [32], in an elaborate review of available literature on hypotension under spinal anaesthesia during caesarean section, found at least 15 different definitions of ‘hypotension’ in the 63 publications retrieved. This resulted in a wide range of the incidence of PSH from 7.4% to 74.1%. The authors reported that even minor changes of the definition cause major differences in the observed incidence of hypotension. This makes comparison between studies difficult and pooling of results nearly impossible.

The present review found 11 different definitions for PSH and 6 for PIH. The timeframe for defining PSH also varied widely, from within 15 minutes of the spinal injection to until the end of surgery. During operations under SA, the most vulnerable period for hypotension is the initial few minutes following sub-arachnoid injection of local anaesthetic. Hypotension occurs primarily due to loss of sympathetic tone in the lower half of the body leading to decreased systemic vascular resistance (SVR) due to arteriolar vasodilation, and loss of venous tone leading to reduced mean systemic filling pressure (MSFP) and reduced venous return [33]. As baroreceptor reflex mechanisms gradually restore SVR and blood volume gradually redistributes, venous return is restored, and blood pressure slowly returns toward baseline. Intravenous fluid boluses and short acting vasopressors are usually used to cover this period of sudden hypotension. There is, however, no specific definition for this period in the literature. After 15–30 minutes of spinal injection, the surgical procedure would obviously have started. At this stage, surgical causes such as positioning, retraction and blood loss will confound blood pressure changes. Therefore, until what time PSH can be attributed to sympatholysis by the SA is a matter of conjecture. Similarly, there is hardly any consensus on the definition of PIH in terms of magnitude or timeframe, in patients undergoing GA. Another important aspect of defining PSH or PIH is what should be considered the baseline value. It is very often observed that even normotensive patients, when wheeled into the operating room, have high blood pressure readings, probably because of preoperative stress or anxiety. Whether such blood pressure readings immediately prior to anaesthesia initiation should be considered as baseline or whether the “usual” blood pressure readings obtained during the pre-anaesthesia visit are to be considered remains unclear.

Aside from differences in definition of hypotension, there was remarkable heterogeneity in different aspects of the studies. The study populations in various studies were diverse. IVC dimensions and indices may be different between parturient and non-parturient patients. The IVCUS imaging and measuring techniques used in various studies were different. While a few studies have used a phased-array probe, others have used the curvilinear probe. The exact point at which the IVC diameter was measured in various studies was inconsistent. None of the studies have specified the M-mode sweep speed used during IVC diameter measurement. This may have affected the number of respiratory cycles sampled for measuring minimum and maximum IVC diameter.

The change in IVC diameter with phases of respiration depends not only on intra-vascular volume but also on the depth of respiration [34, 35]. The deeper the inspiratory effort is, the greater is the fall in intrathoracic pressure and consequent collapse of the IVC. Multiple factors including anxiety, pain, and metabolic acidosis may influence the respiratory efforts in an awake patient and can cause significant variations in the IVC diameter. It is difficult to standardize or quantify the respiratory efforts in a spontaneously breathing patient. Out of the 23 studies screened in this review, 5 have mentioned that measurement was performed during normal quiet breathing. Others however do not specify the breathing pattern during IVCUS. Studies that have reported a correlation between the attenuation of IVC collapsibility and elevated central venous pressure recommend that patients be asked to take a sudden sharp inspiratory effort, also described as a “sniff” test, during inspiratory IVC diameter measurement [36,37]. It is hypothesized that the sniff manoeuvre can standardize the inspiratory effort and, due to its brief nature, can be performed effectively with ease by both normal and dyspnoeic patients. Whether such a manoeuvre was performed in any of the studies in the present review is not clear.

IVC diameter and phasic variability with respiration have been shown to increase with age [38]. Thus, age too can be a confounding factor when comparing studies on IVC indices.

The heterogeneity in the above discussed factors was probably responsible for the conflicting results reported in the studies in this review. Consequently, a very wide range of individual cut-offs, sensitivities and specificities have been reported, making pooled analysis impossible. Hence, we have not proceeded further with a meta-analysis of the data.

In a meta-analysis of studies predicting fluid responsiveness in critically ill patients using the caval index, Orso et al. [6] reported a pooled sensitivity and specificity of 0.71 and 0.75 respectively. However, they pooled data from various studies using different cut-offs, and therefore did not recommend a clear cut-off for the caval index that can accurately predict fluid responsiveness.

The major limitation in our systematic review is that we could not perform a meta-analysis as we did not find enough studies taking the same cut-off values of IVCCI. That has precluded any comparison between age groups or between the pregnant and non-pregnant population, to find out whether IVCUS is useful in a specific subgroup of patients.

In conclusion, the results of studies assessing the utility of IVCCI for predicting AIH are very inconsistent with respect to both the ideal cut-off and dia-gnostic accuracy. IVCCI may be a simple, safe, and useful tool for predicting PSH and PIH. However, as IVC diameter and collapsibility are dependent on the interplay of multiple additional physiological factors such as intra-thoracic pressure, intra-abdominal pressure and venous compliance, a fixed cut-off may not always be reflective of the intravascular volume status. Hence, IVCUS derived parameters should be used in the appropriate clinical context to predict AIH. High-quality studies are needed with standardized methodology in terms of age group, patient population, IVCUS techniques and definition of hypotension before clear recommendations can be made.

Acknowledgements

  1. Assistance with the article: none.

  2. Financial support and sponsorship: none.

  3. Conflicts of interest: none.

  4. Presentation: none.

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