Inferior Vena Cava Distensibility in Patients with SAH, New Technology and Numbers, Better Care?
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EDITORIAL
Inferior Vena Cava Distensibility in Patients with SAH, New Technology and Numbers, Better Care? Clemens M. Schirmer
Published online: 11 May 2010 Ó Springer Science+Business Media, LLC 2010
Sometimes I wonder whether today we take sufficient care to make a thorough physical examination before our patient starts off on the round of the laboratories, which have become so necessary that oftentimes we do not fully appreciate the value of our five senses in estimating the condition of the patient.—William Mayo, Collected papers of the Mayo Clinic, 1938 The use of bedside ultrasound examination by intensivists is a recent development, for the neurocritical care specialist this complements the longstanding experience neurosurgeons and neurologists have with transcranial Doppler examinations for vasospasm. Drs. Moretti and Pizzi report in this issue on their experience using bedside ultrasound examination to predict fluid responsiveness in patients with subarachnoid hemorrhage (SAH), using inferior vena cava distensibility (dIVC) as a parameter that discerns between fluid responders and non-responders. They enrolled 29 adult patients with SAH requiring advanced hemodynamic monitoring, measured the inferior vena cava diameter during a single mechanical breath and the dIVC was calculated. A dIVC value of >16% yielded the best predictive value for volume response. There was a trend toward a lower incidence of delayed ischemic lesions in fluid responders and the dIVC was determined a reliable predictor of fluid responsiveness in patients with SAH [1]. The article might be criticized on multiple levels, one could ask for a larger number of patients or a longer follow-up but more importantly it accomplishes a number of goals for the interested reader—it introduces a new
C. M. Schirmer (&) Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA e-mail: [email protected]
technology application, or better, a new measurement obtainable with the same ultrasound machine that might be already available in the intensive care unit. It makes the case for the dIVC compared to other hemodynamic parameters that attempt to assess volume status in the critically ill patient and establishes its use in the clinical scenario of patients with SAH. Substituting the subjective assessment of a patient’s status by a clinician with objective measures uncouples the assessment from the experience of the clinician taking the measurement. On the other hand, it enables objective comparison and research. Technology may become used in its own right or as a substitute and not as an adjunct for good clinical care. The words of William Mayo above may be a reminder that remains current. A study published in the Lancet a few years ago demonstrated that the findings on physical examination by an attending physician were pivotal in the management of more than a quarter of all medical patients [2]. This should give us more reason for pause and appropriate evaluation of new technology befor
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