|Year : 2021 | Volume
| Issue : 2 | Page : 86-90
Normative data for inferior vena cava diameters and collapsibility index in healthy Indian children from a tertiary care hospital of Chennai
Vidya Ghosh1, Suchitra Ranjit2, Ramakrishnan Balasubramaniam3, Shipra Agrwal1
1 Department of Pediatrics, Yashoda Superspeciality Hospital, Ghaziabad, Uttar Pradesh, India
2 Department of Pediatric Critical Care, Apollo Hospital, Chennai, Tamil Nadu, India
3 Department of Biostatistics, Apollo Hospital, Chennai, Tamil Nadu, India
|Date of Submission||02-Nov-2020|
|Date of Decision||01-Dec-2020|
|Date of Acceptance||20-Dec-2020|
|Date of Web Publication||10-Mar-2021|
Dr. Shipra Agrwal
Yashoda Superspeciality Hospital, Kaushambi, Ghaziabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: An ultrasound evaluation of the inferior vena cava (IVC) collapsibility index (CI) has proven to be an excellent noninvasive method of evaluating hydration in adult patients. There is a lack of normative data on the IVC diameters and CI in Indian children. This study was planned to formulate the normative values for IVC diameter in children and adolescents and to assess its correlation with various somatic parameters in Indian children aged 6 months–16 years.
Subjects and Methods: Children aged 6 months–16 years in good general health, normal hydrations, and without any significant underlying medical condition who were coming to hospital for their treatment in the outpatient department were consecutively enrolled in the study. The maximum and minimum diameters of IVC were measured during the expiratory and inspiratory phase of the respiratory cycle, respectively, using M mode ultrasonography. CI was also calculated for each subject. These values were correlated with age, gender, and body surface area (BSA).
Results: One hundred patients were enrolled in the study, 48 were boys and 52 were girls. The mean (standard deviation) CI was 23.3% (11.9) among males and 20.1% (11.7) among females. The mean maximum and minimum IVC diameter increased significantly with age (r = 0.738, P = 0.00; r = 0.789 P = 0.000) and with BSA (r = 0.73, P = 0.0001; r = 0.77, P = 0.0001). CI did not show significant correlation with age or BSA.
Conclusion: IVC dimensions during inspiration or expiration increases with age and BSA, but same relation does not hold for CI. These values were similar among males and females.
Keywords: Body surface area, collapsibility index, inferior vena cava diameter, ultrasonography
|How to cite this article:|
Ghosh V, Ranjit S, Balasubramaniam R, Agrwal S. Normative data for inferior vena cava diameters and collapsibility index in healthy Indian children from a tertiary care hospital of Chennai. J Pediatr Crit Care 2021;8:86-90
|How to cite this URL:|
Ghosh V, Ranjit S, Balasubramaniam R, Agrwal S. Normative data for inferior vena cava diameters and collapsibility index in healthy Indian children from a tertiary care hospital of Chennai. J Pediatr Crit Care [serial online] 2021 [cited 2021 Apr 20];8:86-90. Available from: http://www.jpcc.org.in/text.asp?2021/8/2/86/311057
| Introduction|| |
Intravascular volume status assessment is an essential component in the management of a sick child. It relies mostly on subjective judgment, clinical judgment, and static measurements, such as central venous pressure (CVP) or pulmonary artery occlusion pressure in adults. The later are invasive and have well-known limitations.,,,,, In children with diarrheal illness, sepsis, or trauma, severe dehydration can lead to hypovolemia, shock, and eventual mortality. Early and rapid fluid resuscitation is the standard recommendation for any child in hypovolemic shock and septic shock.
An ultrasound (US) evaluation of the inferior vena cava (IVC) collapsibility has proven to be an excellent noninvasive method of evaluating hydration in adult patients., Changes in volume status will be reflected in sonographic evaluation of the IVC, where increased or decreased collapsibility of the vessel will help in the clinical management of the patient. The combination of the absolute diameter of the IVC and the degree of collapse with respiration gives an estimate of CVP and a substitute for more invasive measurements. Negative pressure created by the inspiration of the patient increases venous return to the heart, briefly collapsing the IVC. Exhalation decreases venous return and the IVC returns to its baseline diameter.
In states of low intravascular volume, the percentage collapse of the vessel will be proportionally higher than in intravascular volume overload states. This is quantified by caval index or collapsibility index (CI). The CI close to 100% is indicative of almost complete collapse and therefore volume depletion, while a number close to 0% suggest minimal collapse (i.e., likely volume overload)., Poor collapsibility can also indicate diastolic dysfunction of the right ventricle or right atrial hypertension from other causes.
An absolute IVC size of 1.5–2.5 cm with collapsibility of >50% on respiration is consistent with hypovolemia in adult patients., IVC CI of >50% has been found to have sensitivity of 45.5% and specificity of 91.7% to predict CVP of <8 mmHg in children. IVC CI has been found to have strong negative correlation with CVP in both spontaneously breathing and mechanically ventilated pediatric patients.
Although IVC measurements are commonly used parameter for the assessment of fluid status in adults, there is a paucity of data in Indian children. This study was planned to formulate the normative values for IVC diameters and CI in children and adolescents and to assess its relation with age, gender, and body surface area (BSA) in Indian children aged 6 months–16 years.
| Subjects and Methods|| |
This prospective, observational study was conducted at a tertiary care hospital of Chennai from August 2013 to February 2014. Children in the age group of 6 months–16 years who visited the outpatient department (OPD) for routine follow-up or vaccination were consecutively recruited in the study after obtaining informed consent from the parents. Children with significant chronic illness, including chronic lung disease, pulmonary hypertension or other significant pulmonary illness, congenital or acquired heart disease, chronic liver disease, hematological illness, and renal disease, were excluded from the study. Children who were suspected to have abnormal hydration on the examination were also excluded from the study. Ethical permission was obtained from the Institutional Ethics Committee for the study and usage of departmental US machine for the study. Written informed consent was obtained from parent or guardian for each subject
Demographic data such as age and gender were recorded. Weight and height (length for <2 years) were recorded, and BSA was calculated using Mosteller formula (BSA in m2 = square root (ht cm × wt kg/3600). Study participants were all from Southern India.
Children were regrouped into 6 months to 47 months, 48 months to 119 months, and 120 months to 192 months. The US evaluation was done by same radiologist for each patient. IVC dimension were measured using Micromax US system using P10/8-4 MHz probe. The participants were placed in the supine position. The transducer was placed over the subxiphoid region. A long-axis view of IVC was obtained and dimensions of IVC were taken 2 cm distal to the opening of hepatic vein into IVC. The dimension was taken in M mode as maximum diameter of IVC considered as expiratory phase and minimum diameter as inspiratory phase of the respiratory cycle. CI was calculated as the difference between expiratory and inspiratory IVC diameter divided by the expiratory diameter. The index was presented as percentage. Single measurement was recorded. The US evaluation was done only for the assessment of IVC dimensions; other organ assessment was not done. As the patients were recruited from the OPD, nil per oral status was not ensured. Young infants were evaluated in the mothers' presence, and other measures were made (e.g., pacifier) to avoid bias due to crying.
All the continuous variables were assessed for the normality using one sample K-S test. If the variables were following the Gaussian distribution, they were expressed as mean ± standard deviation. All the categorical variables were expressed either as percentage or proportion. All comparisons of nonnormally distributed variables were taken care by Kruskal–Wallis H test for more than two variables and Mann–Whitney U-test for two variables. Pearson correlation coefficient was used to find the association between the continuous variables. All the P < 0.05 was considered statistically significant. Data entry was done in MS-EXCEL spreadsheet. Data were analyzed using the SPSS software version 16.0 (Copyright 2007, SPSS Inc, Chicago, IL, USA).
| Results|| |
One hundred children were enrolled in the study; there were 48 males and 52 females. There was no statistically significance observed between the age groups and gender (P = 0.502) [Table 1].
[Table 2] shows IVC dimensions and CI in different age groups. [Figure 1]a, [Figure 1]b, [Figure 1]c shows box plot showing the range of maximum and minimum IVC diameters and CI. Maximum IVC diameter showed significant positive correlation with age and BSA (r = 0.789, P = 0.00 and r = 0.77, P = 0.00, respectively, for age and BSA). Similarly, minimum IVC diameter also showed a significant positive correlation with age and BSA (r = 0.738 P = 0.000 and 0.73, P = 0.00, respectively, for age and BSA). The correlation of CI with age and BSA was not statistically significant (r = −0.085, P = 0.403 and r = −0.09, P = 0.34, respectively). [Figure 2] reveals the above correlation where IVC diameter during inspiration and expiration is rising linearly with BSA while CI is not [Figure 2]a, [Figure 2]b, [Figure 2]c. Mean CI in the age group of 6–47 months was higher than the other two groups [Table 2]. [Table 3] gives the values of maximum and minimum IVC diameters and collapsibility indices among males and females. There was no statistically significant difference between the two groups.
|Table 2: Inferior vena cava dimensions and collapsibility index in the age groups|
Click here to view
|Figure 1: (a) Box plot showing the range of maximum inferior vena cava diameter (during expiration) in the study population. (b) Box plot showing the range of minimum inferior vena cava diameter (during inspiration) in the study population. (c) Box plot showing the range of collapsibility index in the study population|
Click here to view
|Figure 2: (a) Scatter plot showing linear correlation of maximum inferior vena cava diameter with body surface area. (b) Scatter plot showing linear correlation of minimum inferior vena cava diameter with body surface area. (c) Scatter plot showing collapsibility index in relation with body surface area|
Click here to view
|Table 3: Gender distribution of inferior vena cava dimensions and collapsibility index|
Click here to view
| Discussion|| |
Fluid management is very precarious in children, and it is crucial to know the fluid deficit or overfill the system before administering more fluids. There are some useful methods to assess fluid status, but majority have some limitations. CVP is most commonly used for the assessment of volume status in critical patients, but being an invasive procedure it is associated with many complications. IVC-CI significantly correlates with CVP according to recent studies.
The present study was directed toward establishing normative data for maximum and minimum IVC dimensions and CI, as there is a lack of normative data for children and adolescents in the Indian context.
Similar study done by Taneja et al. showed lower maximum and minimum IVC diameter and higher CI compared to our study. The difference in the findings can be due to the difference in the patient population. Their patient population was from the northern India. Similar to our study, they also showed positive correlation of maximum and minimum IVC diameters with age, and BSA, while CI was almost similar in all age groups.
Haines et al. derived an IVC dimension growth curve as a function of age among the children aged 4 weeks to 20 years and found linear correlation between IVC dimensions and age. The mean IVC dimeters were similar to our study.
Stenson et al. retrospectively studied IVC dimensions from the echocardiography data of children <6 years of age and found that both IVC and aortic diameters increases linearly with BSA and body mass. Similar were the findings in our study.
Kutty et al. studied 120 healthy volunteer children and derived the mean maximum and minimum IVC diameters which were higher than our study. Similar to our study, they also showed good correlation of these diameters with age and BSA while CI was not correlated with age or BSA. Similar were the findings of Patil et al. who derived normative IVC dimensions in the adult population.
Our study also found that CI was higher in the younger age group; this could have been expected as these kids tend to cry during US. Although all efforts were made to avoid children from crying, it may have contributed to the difference.
The strength of the study was prospective study design and inclusion of children of all the age groups. Limitation of our study was small sample size and inclusion of children from a specific region of the country which is not enough to extrapolate these measurements on the general population. The present study has not included severely malnourished children. Hence, these data cannot be extrapolated for malnourished children. Furthermore, the present study has included only the children visiting to authors' hospital, there were no healthy volunteers taken directly from the community. Further studies with larger sample size and inclusion of patients from different regions of the country are required.
| Conclusion|| |
We presented normal maximum and minimum IVC diameters and CI in the pediatric population. The IVC diameters showed a significant positive correlation with age and BSA. Further studies with larger sample size are required to further evaluate the normal values and the correlation of these measurements with age and BSA may also help in derivation of IVC sizes for different age and BSAs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bendjelid K, Romand JA .Fluid responsiveness in mechanically ventilated patients: A review of indices used in intensive care. Intensive Care Med 2003;29:352-60.
Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008;134:172-8.
Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: A critical analysis of the evidence. Chest 2002;121:2000-8.
Muller L, Louart G, Bengler C, Peray PF, Carr J, Ripart J, et al.
The intrathoracic blood volume index as an indicator of fluid responsiveness in critically ill patients with acute circulatory failure: A comparison with central venous pressure. Anesth Analg 2008;107:607-13.
Osman D, Ridel C, Ray P, Monnet X, Anguel N, Richard C, et al
. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med 2007;35:64-8.
Vincent JL, Weil MH. Fluid challenge revisited. Crit Care Med 2006;34:1333-7.
Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, et al
. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 Update from the American college of critical care medicine. Crit Care Med 2009;37:666-8.
Feissel M, Michard F, Faller JP, Teboul JL. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Med 2004;30:1834-7.
Nagdev AD, Merchant RC, Gonzalez TA, Sisson CA, Murphy MC. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. Ann Emerg Med 2010;55:290-5.
Babaie S, Behzad A, Mohammadpour M, Reisi M. A comparison between the bedside sonographic measurements of the inferior vena cava indices and the central venous pressure while assessing the decreased intravascular volume in children. Adv Biomed Res 2018;7:97.
] [Full text]
Ali MK, Naim E. Respiratory variation of inferior vena cava diameter and central venous pressure in ventilated and non-ventilated children in fluid refractory septic shock: An observational study. Int J Contemp Pediatr 2019;6:1947-51.
Wiwatworapan W, Ratanajaratroj N, Sookananchai B. Correlation between inferior vena cava diameter and central venous pressure in critically ill patients. J Med Assoc Thail 2012;95:320-4.
Taneja K, Kumar V, Anand R, Pemde KH. Normative data for IVC diameter and its correlation with the somatic parameters in healthy Indian children. Indian J Pediatr 2018;85:108-112.
Haines EJ, Chiricolo GC, Aralica K, Briggs WM, Amerongen RV, Laudenbach A, et al
. Derivation of a pediatric growth curve for inferior vena caval diameter in healthy pediatric patients: Brief report of initial curve development. Crit Ultrasound J 2012;4:12.
Stenson EK, Punn R, Ramsi M, Kache S. A retrospective evaluation of echocardiograms to establish normative inferior vena cava and aortic measurements for children younger than 6 years. J Ultrasound Med 2018;37:2225-33.
Kutty S, Li L, Hasan R, Peng Q, Rangamani SA, Danford D, et al
. Systemic venous diameters, collapsibility indices, and right atrial measurements in normal pediatric subjects. J Am Soc Echocardiogr 2014;155-62.
Patil S, Jadhav S, Shetty N, Kharge J, Puttegowda B, Ramalingam R, et al
. Assessment of inferior vena cava diameter by echocardiography in normal Indian population: A prospective observational study. Indian Heart J 2016;68:S26-30.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]