Introduction
Patients with decompensated cirrhosis are particularly vulnerable to iatrogenic volume overload, a potential side effect of intravenous (IV) albumin infusion. In a prospective cohort study performed by our group using point of care ultrasound (POCUS) of the inferior vena cava (IVC), we found severe intravascular volume overload in 1/5 patients despite strict adherence to current guidelines1,2. Severe volume overload was associated with higher rates of repeated paracentesis, variceal bleeds and increases in n-terminal pro brain natriuretic peptide. However, changes in volume status during passive leg raise (PLR), an established fluid responsiveness test, could not predict changes observed after IV albumin, most probably due to variable degrees of intra-abdominal pressure caused by ascites. CPMX2 (Compremium AG, Switzerland) is a novel noninvasive medical device that uses compression pressure of the external jugular vein (EJV) to measure central venous pressure, which has been validated in patients requiring intensive care3,4. CPMX2 use in decompensated cirrhosis and its predictive accuracy for post-albumin volume overload still need to be explored.
Aims & Methods
In this prospective pilot study including 20 patients with decompensated cirrhosis and an indication for IV albumin, we aimed to compare IVC-POCUS and CPMX2 of the EJV to assess volume overload at PLR and after IV albumin infusion. Minimal and maximal IVC diameters (IVCmin, IVCmax) as well as IVC collapsibility (IVCCI) using POCUS, and minimal, maximal, and mean EJV compression pressures (EJVmin, EJVmax, EJVmean) using CPMX2 were measured in parallel before and during PLR, as well as before and after IV albumin infusion. Volume overload was defined as IVCmax >2.1 cm and IVCCI <50% using POCUS, and EJVmean ≥9 mmHg for CPMX2 (derived from established criteria for central venous pressure and inherent characteristics of CPMX2)3-5.
Results
In our prospective cohort (35% women, median age 62 years, mean BMI 25.7 kg/m2, 55% Child B, median MELD 15, 80% paracentesis as an indication for IV albumin), all IVC diameters and EJV compression pressures considerably increased during PLR and after IV albumin infusion. Percentage changes in most EJV compression pressures were significantly higher than changes observed in IVC diameters during PLR (mean EJVmax +88.4%/EJVmean +62.6% vs IVCmax +16.4%/IVCmin +25.9%, p<0.01, respectively). On the other hand, percentage changes in the parameters obtained by the two techniques were comparable after IV albumin infusion (mean EJVmax +65.4%/ EJVmin +77.6%, EJVmean +72.0% vs IVCmax +57.6%/IVCmin +78.9%). Intravascular volume overload after IV albumin was very frequent, occurring in the majority of observed cases (POCUS: 65%, CPMX2: 90%).
Conclusion
Both POCUS-based IVC assessment and CPMX2-derived EJV compression pressures detect significant intravascular volume changes during PLR and following IV albumin infusion in patients with decompensated cirrhosis. CPMX2 appeared more sensitive to dynamic changes during PLR and identified a greater proportion of patients with volume overload after IV albumin. These findings suggest that CPMX2 could serve as a promising, noninvasive tool for early characterization of volume status and prevention of iatrogenic volume overload. Further studies are needed to validate these results and to evaluate the use of CPMX2 to tailor intravenous albumin amount in view of a personalized therapeutic approach.
References
1. Segna D et al. SAT-121 Point-of-care ultrasound of the inferior vena cava for intravascular volume assessment in patients with cirrhosis during intravenous albumin infusion. Journal of Hepatology 2024; 80: S254-255
2. Segna D et al. Point-of-care ultrasound of the inferior vena cava for intravascular volume assessment during intravenous albumin infusion in patients with cirrhosis. [under review]
3. Baumann UA et al. Estimation of central venous pressure by ultrasound. Resuscitation 2005; 64:193-9
4. Thalhammer C et al. Non-invasive central venous pressure measurement by compression ultrasound--a step into real life. Resuscitation 2009; 80:1130-6
5. Eskesen et al. Systematic review including re-analyses of 1148 individual data sets of central venous pressure as a predictor of fluid responsiveness. Intensive Care Med 2016; 42:324–332
Disclosure
This study is supported by Compremium AG, Switzerland. Daniel Segna reports travelling fees from Gilead and Falk, unrelated to this project. Annalisa Berzigotti is a consultant for Boehringer-Ingelheim and Astra Zeneca; Speakers’ fees from GE Healthcare and Hologic, unrelated to this project. Jaime Bosch is a consultant for AstraZeneca, NovoNordisk, Boehringer Ingelheim and Resolution Therapeutics. Ulrich Baumann is a Chief Medical Officer of Compremium AG. Benjamin Messerli has nothing to disclose.