الفهرس 
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Abstract
Sepsis is a life threatening infection lead to organ dysfunction caused by
dysregulated hot response. Fluid therapy is one of the most important lines of
therapy in patient with sepsis and septic shock, it improves oxygen delivery to the
tissues and increase cardiac output.
Increasing cardiac output by volume expansion is a corner stone treatment
of critically ill patients with sepsis presumed to have tissue hypo perfusion. Fluid
resuscitation is performed because it is assumed that the heart is operating of the
steep ascending portion of the Frank-Starling curve (preload-responsive).
However, fluid resuscitation in the non-preload-responsive patient may be
deleterious if it promotes cor pulmonale, pulmonary edema, or peripheral edema.
Assessment of intravascular volume status is important in septic patients,
several methods are used to show which patients are fluid responsive. The volume
responsiveness can be defined as a 15% increase in stroke volume (SV) or cardiac
output (CO) after fluid therapy.
This study aims to evaluate the role of internal jugular vein (IJV)as a
dynamic parameter in prediction of fluid responsiveness in septic mechanical
ventilated patients by comparing IJV distensibility index with static parameters
like systolic blood pressure(SBP),diastolic blood pressure(DBP), mean blood
pressure (MBP)and central venous pressure (CVP) and with dynamic parameters
like inferior vena cava( IVC) distensibility index and change in velocity time
integrity (VTI) after resuscitation of patients with fluid therapy.
This prospective single-group observational study was conducted in a
general adult critical care unit (CCU) at Menoufia University Hospital after
approval by our local ethics committee (faculty of Medicine, Menoufia
University), 40 adult patients with sepsis and septic shock were recruited for the
study after obtaining a written informed consent from patient„s first-degree
relative.
On admission to ICU:
All included patients were subjected to thorough clinical evaluation
including history, physical examination, routine laboratory investigations
(coagulation profile, arterial blood gases, serum electrolytes, liver function tests,
kidney function tests, complete urine analysis, random blood sugar, sepsis
markers (CRP, procalcitonin) and cultures from suspected sources of infection
including sputum, urine, blood, wound swab . . . etc. then patients treated
according to our ICU protocol.
Hemodynamic assessment: baseline Heart rate, blood pressure,
temperature, respiratory rate, central venous pressure, oxygen saturation, and
urine output measurement were recorded.
All patients were assessed for organ dysfunction using SOFA score and
mortality was assessed using APACHE11 score which calculated within 24h.
All patients were assessed regarding fluid responsiveness by measurement
of (VTI, IVCDI and IJVDI).
Before volume expansion, Baseline HR, systolic, diastolic and mean arterial
pressures, central venous pressure, and Temperature were monitored and recorded .and also mechanical ventilation parameter (tidal volume,
respiratory rate and PEEP) for each patient.
Dynamic parameters are measured by using Philips ultrasound system 3- to
5-MHz (IVC DI-IJV DI-VTI)
IVC distensibilty index was performed with standard curvilinear phased array
transducer via initial B-mode Para median longitudinal window of the IVC
just proximal to the junction of the hepatic veins that lie approximately 0.5
cm to 3 cm proximal to the right atrium.
IJV was visualized with high-frequency linear array transducer via crosssectional
B-mode window of the short axis of the vessel at the level of the
cricoid cartilage and recognized by compression, color Doppler, and pulsedwave
Doppler sampling, in order to avoid changes in vein diameter unrelated
to respiratory variation, minimal pressure was applied to the probe to ensure
that venous occlusion will not occur Dynamic diameter changes of the target
vein was recorded using M mode to measure maximum and minimum
dimensions over 20-second period of spontaneous respiration.
In mechanical ventilated patients IVC and IJV distensibility index was
measured using formula: distensibility (%)=(max diameter - min diameter) /
min diameter.
Cardiac output was measured according to the equation= stroke volume ×
heart rate.
Stroke volume was measured according to equation =0.785 × LVOT
diameter2 ×LVOT VTI.
We measured the aortic diameter by M-mode (time-motion)
echocardiography was employed at the level of the aortic annulus in a twodimensional
view from the parasternal long-axis window.
Velocity time integral (VTI) was obtained from an apical five-chamber
(pulsed wave through aortic valve).
VTI in this study represent cardiac out put as LVOT diameter stationary
don‟t change with fluid expansion.
Fluid responsiveness was assessed through changes in VTI induced by fluids
resuscitation. Patients were divided into 2 groups: fluid responders, if increase in
VTI (ΔVTI) of ≥15% was obtained after fluids resuscitation, and non-responders
if ΔVTI was <15%.
Data collection:
Initially, data was collected from septic patients regarding demographic
data and patient clinical characteristics including source of infection and ventilator
parameters.
Static parameters (SBP, HR, DBP and CVP) were recorded at base line
before fluid therapy (T0) and 20minutes after resuscitation with 7 mg/kg
crystalloids (T1).
Dynamic parameters (VTI, IVCDI and IJVDI) were recorded at base line
before fluid therapy (T0) and 20minutes after resuscitation with 7 mg/kg
crystalloids (T1).
Data was collected from all patients responder and non- responder.
The most important in this study to evaluate measurements of IJVDI
before fluids resuscitation (T0) and follow up after resuscitation (T1) in responder
and non- responder groups and this was correlated with IVC DI and VTI before
and after fluids resuscitation.
Our study demonstrated that at baseline before fluid therapy static
parameters like (HR, SBP, MAP, DBP and CVP were inadequate for predicting
fluid responsiveness with no significant difference between responders and nonresponders.
Also VTI has no difference between both groups at base line, but IJV
distensibility index and IVC distensibilty Index showed a highly significant
values.
According to ROC curve ,this study showed that IJVDI is a good predictor
for fluid responsiveness with cut-off value 21.9, AUC 0.9, sensitivity 90.9,
specificity 84.4% ,positive predictive value 75%, negative predictive value
97%and accuracy 88% and also a higher values of IJV distensibility index and
IVC distensibilty Index are a good predictors for fluid responsiveness with cut -
off value 40.4 (IJV distensibility index value 21.9 –IVC distensibilty Index value
18.5) with a sensitivity of 96% and specificity of 87%, positive predictive value
87.5% ,negative predictive value 95% and accuracy 96% .
Measurements 20 minutes after fluid therapy, our study showed that
responder group had a significant decrease in heart rate and increase in SBP, with
no change in DBP pressure and CVP, also showed a decrease in IVC and IJV
distensibility index.
Our study showed also that no correlation between IVCD and IJVD
indices with VTI neither before nor after fluid therapy. However, there is a strong
negative correlation between difference in VTI and difference IJVD and IVCD
indices before and after fluid therapy and showed also a strong correlation
between IJVDI and IVCDI at base line.
Using IJV distensibility index provided an easy non -invasive method used
in septic mechanical ventilated patients helped to know fluid responder patients
from not this leaded to improve SOFA score of patients, decrease mortality,
decrease complication of fluid over load, decrease doses of vasopressor in fluid
responder patients and early apply vasopressor in non –responder patients.