How to assess fluid status with handheld ECHO

26th Nov 2020

Critically-ill patients with COVID-19—who are at risk of organ failure—require careful assessment of their filling status to ensure optimal cardiac output and oxygen delivery. 

However, the clinical assessment of a patient’s volume status can be challenging and frequently inaccurate. Poorly guided administration of intravenous fluid can have a negative impact on fluid status, due to inadequate or overaggressive fluid therapy. 

Using handheld echocardiography (HHE) to assess the left ventricle, right ventricle, and inferior vena cava (IVC) can provide key insights on a patient’s fluid status. 

Multi-component illustration of heart with left ventricle, right ventricle, and inferior vena cava highlighted.

Figure 1. A patient’s volume status can be assessed by imaging the left ventricle, right ventricle, and inferior vena cava with handheld echocardiography (HHE). 

Handheld echocardiography can be useful for cases where fluid balance is challenging, such as renal failure in a patient with COVID-19. 

So, how do you assess a patient’s fluid status with HHE?

 

Predicting fluid status with left ventricular imaging

Left ventricular (LV) cavity size and wall thickness can be useful predictors of fluid status. A small, hyperdynamic left ventricle is related to low preload, which suggests that the patient is underfilled and volume-depleted. In this hypovolemic state, the cavity of the left ventricle can collapse and exhibit the kissing sign. Moreover, the myocardial walls in an underfilled patient may appear thickened. 

Left ventricle echocardiogram highlighting small ventricular cavity size and hyperdynamic left ventricular systolic function in patients with COVID-19.

Figure 2. Left ventricular (LV) cavity size and wall thickness can be useful when assessing fluid status. Underfilled patients can display a small, collapsed left ventricle exhibiting a kissing sign. PSAX, parasternal short-axis view. 

Check out this short video clip from our COVID Mini: Handheld ECHO Course that highlights the kissing sign:

 

 

Predicting fluid status with right ventricular imaging

Assessment of the right ventricle (RV) can also provide useful information on volume status. The right ventricle is a compliant chamber and can dilate to accommodate increased volume loading—but tolerates acute pressure loading poorly. 

Therefore, a dilated right ventricle suggests that the ventricle is volume-loaded, which should prompt caution in fluid administration. 

Echocardiogram showing a dilated right ventricle beside a caution sign.

Figure 3. Right ventricle cavity size and thickness can predict fluid status. Overloaded patients with COVID-19 can display a dilated right ventricle and should prompt cautious fluid administration. 

Septal flattening and progressively increasing severity of tricuspid regurgitation (assessed by color Doppler view) can also be useful for estimating right heart pressure. 

These markers also suggest right-sided volume and pressure overload, which can be helpful for guiding fluid management.  

 

Clickable call to action, "Start learning for free", with direct link to sign up for a free Medmastery trial account.

Septal flattening on PSAX echocardiogram image and tricuspid regurgitation on color Doppler.

Figure 4. Assessment of the tricuspid valves using color Doppler can be useful for predicting fluid status. Overloaded patients may display septal flattening and tricuspid regurgitation. PSAX, parasternal short-axis view.

Check out this short video clip from our COVID Mini: Handheld ECHO Course that highlights septal flattening and tricuspid regurgitation in overloaded patients with COVID-19:

 

 

Predicting fluid status with inferior vena cava imaging

Inferior vena cava (IVC) size and collapsibility can also provide guidance on a patient’s volume status. 

Ventilated patients, particularly those ventilated with positive pressure, typically have a dilated IVC with minimal respiratory variation and without raised right atrial pressure. 

Echocardiogram highlighting a normal dilated inferior vena cava (IVC) in a ventilated patient.

Figure 5. Inferior vena cava (IVC) size and collapsibility can predict volume status in ventilated patients. In ventilated patients without raised right atrial pressure (normal), the IVC is dilated with minimal respiratory variation. 

Check out this short video clip from our COVID Mini: Handheld ECHO Course that highlights the minimal respiratory variation of the IVC in a ventilated patient:

 

However, if the IVC is small and collapsing (typically more than 50%), this suggests an underfilled state. As well, a dilated IVC with no variation in size may be a sign of hypervolemia, which should prompt cautious fluid administration. 

Echocardiograms highlighting a small inferior vena cava (IVC) in an underfilled patient and a dilated IVC in an overfilled patient.

Figure 6. Inferior vena cava (IVC) size and collapsibility can predict fluid status in ventilated patients. Underfilled patients display a small, collapsing IVC, and overfilled patients display a dilated IVC. 

Check out this short video clip from our COVID Mini: Handheld ECHO Course that highlights the relationship between IVC size and collapsibility and fluid status in ventilated patients:

 

That’s it for now. If you want to improve your understanding of key concepts in medicine, and improve your clinical skills, make sure to register for a free trial account, which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients.

Recommended reading

  • Chamsi-Pasha, MA, Sengupta, PP, and Zoghbi, WA. 2017. Handheld echocardiography: Current state and future perspectives. Circulation136: 2178–2188. PMID: 29180495
  • Clerkin, KJ, Fried, JA, Raikhelkar, J, et al. 2020. COVID-19 and cardiovascular disease. Circulation141: 1648–1655. PMID: 32200663
  • Doyen, D, Moceri, P, Ducreux, D, et al. 2020. Myocarditis in a patient with COVID-19: A cause of raised troponin and ECG changes. Lancet395: 1516. PMID: 32334650
  • Drake, DH, De Bonis, M, Covella, M, et al. 2020. Echocardiography in pandemic: Front-line perspective, expanding role of ultrasound and ethics of resource allocation. J Am Soc Echocardiogr33: 683–689. PMID: 32503707
  • Fukuhara, S, Rosati, CM, and El-Dalati, S. 2020. Acute type A aortic dissection during the COVID-19 outbreak. Ann Thorac Surg. 110: e405–e407. PMID: 32333849
  • Haji, K, Wong, C, Neil, C, et al. 2019. Handheld ultrasound to reduce requests for inappropriate echocardiogram (HURRIE). Echo Res Pract6: 91–96. PMID: 31516721
  • Hua, A, O’Gallagher, K, Sado, D, et al. 2020. Life-threatening cardiac tamponade complicating myo-pericarditis in COVID-19. Eur Heart J41: 2130. PMID: 32227076
  • Johri, AM, Galen, B, Kirkpatrick, JN, et al. 2020. ASE statement on point-of-care ultrasound during the 2019 novel coronavirus pandemic. J Am Soc Echocardiogr33: 670–673. PMID: 32503704
  • Meyer, P, Degrauwe, S, Van Delden, C, et al. 2020. Typical takotsubo syndrome triggered by SARS-CoV-2 infection. Eur Heart J41: 1860. PMID: 32285915
  • Neskovic, AN, Hagendorff, A, Lancellotti, P, et al. 2013. Emergency echocardiography: The European association of cardiovascular imaging recommendations. Eur Heart J Cardiovasc Imaging14: 1–11. PMID: 23239795
  • Nguyen, VTQ, Ho, JE, Ho, CY, et al. 2008. Handheld echocardiography offers rapid assessment of clinical volume status. Am Heart J156: 537–542. PMID: 18760138
  • Poissy, J, Goutay, J, Caplan, M, et al. 2020. Pulmonary embolism in patients with COVID-19: Awareness of an increased prevalence. Circulation142: 184–186. PMID: 32330083
  • Shi, S, Qin, M, Shen, B, et al. 2020. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol5: 802–810. PMID: 32211816
  • The American Society of Echocardiography. ASE statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. 2020. ASEcho.org. https://www.asecho.org  
  • The American Society of Echocardiography. Cleaning recommendations from ultrasound manufacturers. 2020. ASEcho.org. https://www.asecho.org
  • The Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS) and Public Health England. COVID-19: Guidance for infection prevention and control in healthcare settings. Version 1.0. 2020. rcslt.org. https://www.rcslt.org 
  • Zeng, JH, Liu, YX, Yuan, J, et al. 2020. First case of COVID-19 complicated with fulminant myocarditis: A case report and insights. Infection48: 773–777. PMID: 32277408