On table POCUS assessment for the IVC following abdominal packing: how I do it
Abu-Zidan World Journal of Emergency Surgery
On table POCUS assessment for the IVC following abdominal packing: how I do it
Fikri M. Abu-Zidan 0
0 Department of Surgery, College of Medicine and Health Sciences, UAE University , Al-Ain , United Arab Emirates
Background: Some surgeons may lack proper experience in abdominal packing. Overpacking may directly compress the inferior vena cava (IVC). This reduces the venous return and possibly causes hypotension. Here, a new on table Point-of-Care Ultrasound application that has been recently used to assess the effect of abdominal packing on the IVC diameter is described. Following abdominal packing, a small print convex array probe with low frequency (2-5 MHz) is used to visualize the IVC. Using the B mode, the IVC can be directly evaluated through a hepatic window between the ribs. The ultrasound beam should be vertical to the IVC longitudinal section at its midpoint. The abdominal towels will be in front of the IVC. This will enable us to judge whether there was overpacking on the IVC. Results: Our method demonstrates that overpacking does not compress the IVC in a patient whose blood pressure has improved. The IVC diameter progressively increases on table and in the ICU with active resuscitation implying that bleeding stopped and the resuscitation was successful. Furthermore, presence of intra-peritoneal fluid can be excluded. Conclusions: This new application of ultrasound evaluation of IVC patency after abdominal packing is simple, practical, easily reproducible, and can guide a less experienced surgeon in determining if overpacking of the abdomen is the cause of hypotension. Ultrasound findings should be correlated with the clinical picture to be useful.
Abdomen; Point-of-care ultrasound; IVC; Packing
Abbreviations: IVC, Inferior vena cava; POCUS, Point-of-care ultrasound; ICU, Intensive care unit; DCS, Damage control
Abdominal packing is a useful simple technique which is
used in damage control surgery (DCS) to stop severe
bleeding in multiply injured patients who are acidotic,
hypothermic and coagulopathic [
]. This stabilises the
patient and gives time to restore the physiological
derangement through damage control resuscitation [
]. Finally, the
patient can be timely reoperated upon to restore the
functional anatomy [
]. In addition, surgeon-performed
Point-of-Care Ultrasound (POCUS) has become an
important critical decision making tool in managing
critically-ill patients [
]. Both DCS and POCUS have
been used successfully in the military and prehopsital
Some surgeons may lack proper experience in
abdominal packing and possibly overpack the abdomen.
Overpacking has side effects. The packs and its associated
increased intra-abdominal pressure may directly compress
the inferior vena cava (IVC). This reduces the venous
return and may cause hypotension. Furthermore,
transportation time can be long before arriving to a proper
hospital. It is therefore reasonable to aim at proper
intra-abdominal packing that stops bleeding but without
obliterating the IVC. Sonographic measurement of the
IVC diameter has been recently advocated in the
evaluation of patients in hemorrhagic or septic shock
]. POCUS machines are now usually available in
surgical theatres because they are used routinely in
inserting sonographic guided central lines. It would be
then attractive to evaluate the IVC patency by POCUS
following abdominal packing for DCS. The author of
the present paper has recently reviewed the literature
on the use of ultrasound measurement of IVC
diameter in resuscitation . The relative change of IVC
diameter in trauma patients could differentiate
between proper resuscitation responders from
transient responders who develop recurrent shock [
measurement was feasible in 92 % of patients having
septic shock [
]. Using ultrasound in evaluating the
IVC following abdominal packing was not described
before. The present paper describes a recent on table
POCUS application that can be used to assess the
effect of abdominal packing on the IVC diameter
A small print convex array probe with low frequency
(2–5 MHz) should be used. Ultrasound waves are
generated perpendicular to the surface of this probe. This
probe has deep sonographic penetration and wide view.
It will enable sonographic visualization of the IVC
between the ribs and through a hepatic window to directly
measure the antero-posterior section of the IVC [
There is usually no intra-peritoneal sonographic air
barrier hindering the view if this approach was used.
The probe should be covered by sterile gel and plastic
sleeve. Sufficient sterile gel should be used to have
proper contact with the skin so that the air does not
disturb the view. There are three windows in which we
can visualize the IVC by ultrasound: the subxiphoid,
the direct sagittal and the coronal view (Fig. 1). The
marker of the probe should point proximally towards the
head. This will be on the right side of the ultrasound
screen. The probe is located at the right mid-clavicular
line, at the lower chest wall, and vertical to the skin (Fig. 2).
It is then shifted in both lateral directions to locate the
IVC. Gentle slow lateral fanning movements may be
needed to locate the IVC. It may be required to tilt the
probe a little towards the right shoulder to be parallel to
the IVC (Fig. 3). The commonly used subxiphoid view
cannot be used following damage control laparotomy for
different reasons. First, the midline laparotomy and its
dressing will be in the way. Second, the presence of
distended stomach and free intra-peritoneal air will hinder
the view, and third, the abdomen may be left open. The
coronal section will cut the IVC transversely and will not
measure the antero-posterior diameter of the IVC.
Using the B mode, the IVC can be evaluated in its
longitudinal diameter. The ultrasound beam should be
vertical to the IVC longitudinal section at its midpoint
(Figs. 4 and 5). The IVC will be black in color on the B
mode ultrasound image. The abdominal towels will
appear as whitish linear layers without shadowing
(behaving like a fibrous tissue) anterior to the IVC. This will
show whether the IVC is compressed or not (Fig. 6).
Our method serves to assess excessive pressure on the
IVC in abdominal packing (Fig. 6). The IVC diameter
progressively increases on table and in the ICU with
active resuscitation implying that bleeding stopped and the
resuscitation was successful (Fig. 7). Furthermore,
presence of intra-peritoneal fluid can be detected.
The value of POCUS in the management of patients in
hemorrhagic or septic shock using specific protocols is
]. Our group routinely follows the
Rapid Ultrasound in Shock (RUSH) protocol which
examines the pump (heart), tubes (great vessels) and
reservoir (free intra-peritoneal or intra-thoracic fluid) .
Performing an on table RUSH protocol directly
following DCS is very attractive. Using the same approach, it
would be logical to evaluate the IVC patency by POCUS
following abdominal packing. POCUS is quick, done
bedside and does not interfere with reuscitation. It may
yield very useful information during the continuation of
damage control resuscitation on the operating table after
the damage control laparotomy and before transferring
the patient to the ICU.
The skin was closed with towel clips following
abdominal packing without closure of the fascia in the patient
shown in Fig. 2 because we were anticipating to close
the fascia within 48 hours without the development of
postoperative abdominal hypertension. There are
different methods for temporary abdominal closure that has
been recently detailed in a position paper published by
the World Society of Emergency Surgery [
Advantages and disadvantages of each of these techniques were
described in detail in that paper which is beyond the
scope of the present communication. These techniques
included the plastic silo, negative pressure therapy (NPT),
and the combined NPT with fascial approximation. The
most extensively used method is NPT while the most
promising one is the combined NPT with fascial
approximation. Using our described ultrasound approach, POCUS
can be applied with all these different techniques of closing
the abdomen because a transthoracic hepatic ultrasound
window is away from the wound.
Sonographic appearance of intra-peritoneal free air
has been described in detail [
]. They result from
reflections of the ultrasound waves at the interface
between the soft tissue and air. This is accompanied by a
reverberation artefact. This artefact typically appears as
increased echogenicity of a peritoneal stripe
accompanied by posterior reverberation parallel echogenic lines
having equal distances that will hide the organs. This
image can be changed by changing the patient's position.
The echogenic appearance of the intra-abdominal towels
(as shown in Fig. 6) is different. The echogenic lines are
not parallel, not of the same length, not at equal distances,
and finally they do not hide the liver. Although these
ultrasound fine details can be observed by an experienced
sonographer, they are not needed for evaluating the
IVC diameter which can be done by a less experienced
Weekes et al. [
] prospectively studied trauma
patients and found that gross appearance of the IVC size
agreed with the actual measured IVC diameter during
resuscitation. A meta-analysis, which included a total of
86 hypovolemic patients and 189 controls, found that
IVC diameter was significantly less in hypovolemic
patients compared with controls [
]. A recent prospective
randomized controlled trial in injured patients having
hypotension or tachycardia treated in a Level I trauma
] found that focused ultrasound studies of the
heart and IVC significantly reduced the IV fluid
requirements and the time to surgery. We have recently reported
that increased intra-abdominal pressure in abdominal
compartment syndrome causes direct pressure on the IVC
which reduces the antero-posterior IVC diameter [
Our method is logically more useful when the blood
pressure of the patient improves. Its value may be
questionnable when the patient significantly continues to
bleed because the sonographic IVC diameter will be
small. Nevertheless, we have to clarify that active
intraabdominal arterial bleeding does not respond to packing
and should be actually dealt with surgically. However, on
table POCUS is useful in detecting an on going
intraperitoneal bleeding. In a patient with improving blood
pressure, the IVC diameter will increase indicating that
IVC was not overpacked, bleeding stopped, and the
resuscitation was successful.
This new application of ultrasound evaluation of IVC
patency after abdominal packing is simple, practical, easily
reproducible, and can guide a less experienced surgeon in
determining if overpacking of the abdomen is the cause of
hypotension. Ultrasound findings should be correlated
with the clinical picture to be useful.
The author thanks Mr Cyrus Tariq Gill, RCS, RDCS (ADULT ECHO), Adult
Echocardiographer, Department of Medicine, College of Medicine and Health
Sciences, UAE University, Al-Ain, United Arab Emirates, for fruitfull discussions
during writing this manuscript.
Availability of data and materials
The clinical details of the patient who is shown in the figures has already
been published [
]. The present communication aims to describe and
illustrate in detail the technique used in measuring the IVC by portable
ultrasound so that other colleagues can reproduce it. It was not meant to
report the patient’s clinical details and his images were used only as an
The author performed the Point-of-Care Ultrasound studies and surgery, read
the literature, wrote first version of the paper, edited it, and approved its final
The author declares no conflict of interest.
Consent for publication
Written informed consent was obtained from the patient’s caregiver for the
publication of the images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
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