INTERACTIONS BETWEEN CENTRAL VENOUS PRESSURE AND COLLAPSIBILITY INDEX OF INTERNAL JUGULAR VEIN IN PATIENTS WITH TRAUMA AND BLOOD LOSS.
Izhevsk State Medical Academy,
City Clinical Hospital No.9, Izhevsk, Russia
Along with such hemodynamic parameters as arterial pressure, heart rate and cardiac index, the significant importance relates to the value of central venous pressure (CVP), which is used for estimating the volemic status in patients with injuries and blood loss [1]. Acute blood loss is accompanied by different degrees of volemia and may cause hemorrhagic shock and multiple organ dysfunction [2, 3]. As result, the timely diagnostics of bleeding, estimation of blood loss and hypovolemia degrees are of primary significance during anesthetic and intensive care for a patient with injuries. It is believed that CVP < 5 cm of H2O indicates hypovolemia [4]. The conventional technique of CVP estimation should include preliminary placement of the venous catheter into the subclavian and internal jugular vein. There are some known complications after central venous catheterization such as pneumo- and hemothorax, injuries to nerve bundles, arteries and the pericardium [5, 6]. Therefore, the evident advantages are associated with non-invasive estimation of central venous pressure and the volemic status in patients with trauma and blood loss.
The results of the previous studies showed the high level of correlation between the index of the inferior vena cava collapse and the value of central venous pressure in adults [7]. However this technique has some limitations for some diseases and injuries [8]. At the same time, some studies show the possibilities for estimating the volemic status by means of ultrasonic examination of the internal jugular vein (IJV) [9, 10]. As result, the study of the relationship between CVP and the collapse index of IJV may be actual in patients with injury and blood loss.
The objective of the study – to research the dependence between central venous pressure and the collapsibility index of the internal jugular vein in patients with trauma.
MATERIALS AND METHODS
The ultrasonic examination of the right internal jugular vein was conducted for 30 patients with injuries immediately after admission to the anesthesiology and intensive care unit. The study included the adult male and female patients (age of 18-74) with spontaneous breathing. The exclusion criteria were the age > 74, a cervical injury and necessity for artificial lung ventilation. The severity of the patients’ condition was estimated with Injury Severity Score (ISS). Blood loss was estimated with the ATLS classification developed by American College of Surgeons [11]. The ultrasonic examination of the veins was conducted with ALPINIONE-CUBE 9 (South Korea) and the lineal transducer (5-14 MHz). The maximal and minimal sizes of the diameter of IJV were registered in M-mode. CVP was measured with the direct technique after placement of the intravascular catheter (BBraun CertofixMonoV 420) into the central vein and subsequent radiologic control of its position. Before CVP measurement the patients were placed into the horizontal position on their back. The null point of the phlebomanometer scale was installed at the level of the intersecting point of the 4th rib with the middle axillary line to the right.
The statistical analysis of the data was conducted with Statistica 10 (Statsoft). The quantitative data are presented as mean arithmetical (M), standard deviation (SD), median (Me), range of values (Min-Max) and the collapse index (CI). The collapse index is calculated with the formula: maximal diameter (D max.) – minimal diameter (D min.) / maximal diameter (D max.) * 100 %.
The critical level of significance for testing the statistical hypotheses was ≤ 0.05. Spearman’s test was used for estimating the relationship between several independent variables.
The study design was approved by the ethical committee of Izhevsk State Medical Academy and corresponded to the principles of Helsinki World Medical Declare.
RESULTS
The study included 30 patients who were distributed into 2 groups depending on CVP indices. The group 1 (n = 13) consisted of the patients with CVP ≤ 4 cm H2O, the group 2 (n = 17) – with CVP ≥ 5 cm H2O.
Table 1. The main characteristics of the study groups
|
Main characteristics |
Group 1 |
Group 2 |
|
CVP ≤ 4 cm H2O |
CVP ≥ 5 cm H2O |
|
| n = 13 | n = 17 | |
|
Mean age, years M ± SD |
46.3 ± 9.8 |
46.0 ± 11.2 |
|
Gender |
74.6 / 25.4 | 76.5 / 23.5 |
|
Injury Severity Score (ISS), points |
30.6 ± 2.1 | 27.1 ± 1.8 |
Note: CVP- central venous pressure
The analysis of the clinical data (ATLS) identified the following volumes of blood loss: type 2-3 in the group 1 (1,500-2,000 ml), types 1-2 in the group 2 (up to 1,500 ml). Therefore, increasing volume of blood loss was accompanied by decreasing CVP.
The ultrasonic examinations of the right internal jugular vein identified some differences in the patients with low and normal values of CVP (the table 2).
Table 2. The ultrasound examinations of the right internal jugular vein (IJV)
| IJV characteristics |
Group 1 |
Group 2 |
|
CVP ≤ 4 cm H2O |
CVP ≥ 5 cm H2O |
|
| n = 13 | n = 17 | |
|
CVP, cm H2O |
1.7 ± 1.4 | 8.1 ± 1.6 |
|
Median [range] |
2 [0 - 4] | 8 [5 - 10] |
|
D min, mm |
2.8 ± 1.7 | 8.6 ± 4.3 |
|
Median [range] |
3.5 [0.1 - 4.6] | 8.8 [1.1 - 19.6] |
|
D max, mm (М ± SD) |
7.0 ± 2.9 | 11.6 ± 3.4 |
|
Median [range] |
7.6 [2 - 10.6] | 12 [6.6 - 21.4] |
|
Collapsibility index, % |
60.5 ± 23.6 | 29.3 ± 21.7 |
|
Median [range] |
54.2 [23.5 - 99] | 28.8 [4.3 - 88.1] |
Note: CVP- central venous pressure; IJV - internal jugular vein; D min - minimal diameter; D max - maximal diameter
The correlation relationship was found between CVP and the mean values of the internal jugular veins and the collapse index (the table 3).
Table 3. Spearman's correlation coefficient between CVP and the obtained values
| IJV characteristics |
Group 1 |
Group 2 |
|
CVP ≤ 4 cm H2O |
CVP ≥ 5 cm H2O |
|
| n = 13 | n = 17 | |
|
D min, mm (М ± SD) |
-0.71 | 0.19 |
|
D max, mm (М ± SD) |
0.02 | 0.31 |
|
Collapsibility index, % |
0.64 | 0.07 |
Note: The indicated corelations are significant for p < 0.05; CVP- central venous pressure; IJV - internal jugular vein; D min - minimal diameter; D max - maximal diameter.
DISCUSSION
Monitoring of the hemodynamic values, particularly central venous pressure, is important for estimation of the volemic status in patients with injuries. Since an injury is sometimes accompanied by acute external and/or internal bleeding leading to the absolute deficiency in the volume of circulating blood, development of hemorrhagic shock, hypoxia and death, then the timely estimation of the volemic status is of great importance during planning the medical care [2, 12].
It is believed that CVP < 5 cm H2O indicates the hypovolemia requiring for infusion therapy. Currently, there are some invasive and non-invasive techniques of CVP estimation [4, 7]. Despite of safety and information capacity of non-invasive estimation of the volemic status by means of ultrasonic examination of the collapse index of the inferior vena cava, some objective limitations of practical use exist.
As result, at the present time the researchers have been searching the alternative non-invasive techniques of estimation of the volemic status, for example, with estimating the index of collapse of the internal jugular vein. There are some results of the studies of the internal jugular vein in healthy individuals before and after blood loss (450 ml) demonstrating the contradictory findings of information capacity of IJV collapse index for estimation of the volemic status [13, 14]. A significant disadvantage of these studies was the absence of CVP control that decreased the information capacity of the results.
The advantage of our study was estimation of the relationship between IJV collapse index and CVP in patients with injuries and blood loss. The correlation of middle severity was identified between IJV collapse index and CVP in patients with hypovolemia (CVP ≤ 4 cm H2O). It indicates the possibility for use of this non-invasive technique for estimating the hypovolemia in patients with injury. If the collapse index is more than 60 %, the predicted value of CVP ≤ 4 cm H2O. The results of our studies confirm the previous findings of the study, which showed the high sensitivity and specificity of this technique for estimating the volemic status in patients [15].
CONCLUSION
The value of central venous pressure in patients with injuries depends on the collapse index of the internal jugular veins. Hypovolemia can be predicted, when IJV collapse index > 60 %. Additional studies are required for confirming the accuracy of the results.
REFERENCES
1. Chiu WC. Cardiovascular Monitoring. In: Trauma. Critical care. Wilson WC, Grande CM, Hoyt DB, editors. New York : Informa Healthcare USA, Inc., 2007. Vol. 2. P. 162-163
2. Agadzhanyan VV, Ustyantseva IM. Scientific-practical conception of polytrauma management. Polytrauma. 2013; 2 : 5-10. Russian ( Агаджанян В.В., Устьянцева И.М. Научно-практическая концепция лечения политравмы // Политравма. 2013. № 2. С. 5-10)
3. Urakov AL, Urakova NA, Kasatkin AA. Thermal imaging improves the accuracy of hemorrhagic shock diagnostics: the concept and practical recommendations. LAP Lambert Academic Publishing, 2016. P. 60
4. Guerin L, Monnet X, Teboul JL. Prediction of fluid responsiveness: an update. Ann Intensive Care. 2016; 6 (1): 111
5. Kasatkin AA, Urakov AL, Shchegolev AV, Nigmatullina AR. Internal jugular vein cannulation without the risk of double wall punctures. J Emerg Trauma Shock. 2016; 9: 157
6. Lorchirachoonkul T, Ti LK, Manohara S, Lye ST, Tan SA, Shen L, Kang DS. Anatomical variations of the internal jugular vein: implications for successful cannulation and risk of carotid artery puncture. Singapore Med J. 2012; 53 (5): 325-328
7. Stawicki SP, Adkins EJ, Eiferman DS, Evans DC, Ali NA, Njoku C et al. Prospective evaluation of intravascular volume status in critically ill patients: does inferior vena cava collapsibility correlate with central venous pressure? J Trauma Acute Care Surg. 2014; 76 (4): 956-963
8. Bauman Z, Coba V, Gassner M, Amponsah D, Gallien J, Blyden D et al. Inferior vena cava collapsibility loses correlation with internal jugular vein collapsibility during increased thoracic or intra-abdominal pressure. J Ultrasound. 2015; 18: 343–348
9. Urakov AL, Kasatkin AA, Nigmatullina AR. The dynamics of changing internal jugular veins diameter based on increasing head elevation angle. Indian J Crit Care Med. 2015; 19: 610-612
10. Kent A, Patil P, Davila V, Bailey JK, Jones C, Evans DC, 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
11. Bouglé A, Harrois A, Duranteau J. Resuscitative strategies in traumatic hemorrhagic shock. Annals of Intensive Care. 2013; 3: 1
12. Agadzhanyan VV, Kravtsov SA, Shatalin AV, Levchenko TV. Hospital mortality in polytrauma and main directions for its decrease. Polytrauma. 2015; 1: 6-15. Russian (Агаджанян В.В., Кравцов С.А., Шаталин А.В., Левченко Т.В. Госпитальная летальность при политравме и основные направления ее снижения // Политравма. 2015. №1. С. 6-15)
13. Unluer EE, Kara PH. Ultrasonography of jugular vein as a marker of hypovolemia in healthy volunteers. Am J Emerg Med. 2013; 31 (1): 173-177
14. Akill NB, Cander B, Dundar ZD, Koylu R. A new parameter for the diagnosis of hemorrhagic shock: jugular index. J Crit Care. 2012; 27 (5): 530.e13-8
15. Siva B, Hunt A, Boudville N. The sensitivity and specificity of ultrasound estimation of central venous pressure using the internal jugular vein. J Crit Care. 2012; 27(3): 315. e7-11