Compression pressure of the external jugular vein for the assessment of intravascular volume status in decompensated cirrhosis: A pilot study

TL;DR

A new device called CPMX2 may better detect fluid overload in cirrhosis patients after albumin treatment compared to traditional ultrasound methods.

Contribution

CPMX2 shows greater sensitivity in detecting dynamic volume changes during passive leg raise and after albumin infusion in decompensated cirrhosis.

Findings

CPMX2 detected larger percentage changes in compression pressures during passive leg raise compared to POCUS-IVC.

CPMX2 identified more patients with potential post-albumin volume overload than POCUS-IVC.

Both methods showed significant volume shifts during passive leg raise and after IV albumin.

Abstract

Patients with decompensated cirrhosis are susceptible to iatrogenic hypervolemia. A pilot study using point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) found severe hypervolemia in 20% of patients after intravenous (IV) albumin, despite adherence to current guidelines. CPMX2 is a novel non-invasive device that uses external jugular vein (EJV) compression to assess central venous pressure, but its ability to predict post-albumin hypervolemia has not been studied. We aimed to track changes in intravascular volume status during passive leg raise (PLR) and IV albumin using both methods.

IVC diameters (IVCmin, IVCmax) and IVC collapsibility index (IVCCI) were measured by POCUS, and EJV compression pressures (EJVmin, EJVmax, EJVmean) were measured by CPMX2, in parallel before and during PLR, as well as before and after IV albumin. Potential intravascular overload was defined as IVCmax >2.1 cm and IVCCI <50%, or EJVmean ≥9 mmHg.

In this prospective cohort of 20 patients (35% women; median age 62 years; mean BMI 25.7 kg/m2; 55% Child-Pugh B; 80% receiving paracentesis), all IVC diameters and EJV compression pressures increased during PLR and after IV albumin. Percentage changes in EJV compression pressures were greater than changes in IVC diameters during PLR (mean EJVmax +88%, EJVmean +65% vs. IVCmax +16%, IVCmin +26%; all p <0.01). After IV albumin, changes were comparable between the methods (mean EJVmax +68%, EJVmin +80%, EJVmean +75% vs IVCmax +58%, IVCmin +79%). Potential post-albumin volume overload occurred in most cases (POCUS 65%, CPMX2 95%).

Both POCUS and CPMX2 detected substantial volume changes during PLR and following IV albumin. CPMX2 appeared more sensitive to dynamic changes during PLR and identified more patients with potential post-albumin volume overload, suggesting it may help individualize fluid management in decompensated cirrhosis.

Intravascular volume overload after albumin infusion is a major concern in patients with decompensated cirrhosis and was observed in its most severe form in 20% of patients using POCUS-IVC (point-of-care ultrasound of the inferior vena cava). In this pilot study, we detected substantial volume shifts during passive leg raise and after albumin infusion using both POCUS-IVC and a novel external jugular vein compression technique (CPMX2) in parallel. CPMX2 appeared more sensitive to dynamic changes during passive leg raise and identified a larger proportion of patients with intravascular volume overload following intravenous albumin. These findings suggest that CPMX2 could serve as a promising non-invasive tool for early assessment and individualized monitoring of volume status in decompensated cirrhosis.

Image 1

•POCUS and CPMX2 detected significant intravascular volume changes during PLR and after IV albumin.•Both CPMX2 and POCUS identified a high frequency of potential post-albumin volume overload.•CPMX2 was more sensitive than POCUS for detecting dynamic volume shifts during PLR.•CPMX2 may enable individualized fluid management in decompensated cirrhosis after further validation.

POCUS and CPMX2 detected significant intravascular volume changes during PLR and after IV albumin.

Both CPMX2 and POCUS identified a high frequency of potential post-albumin volume overload.

CPMX2 was more sensitive than POCUS for detecting dynamic volume shifts during PLR.

CPMX2 may enable individualized fluid management in decompensated cirrhosis after further validation.

Figures