Correspondence Address:
Amarjeet Kumar
Room No 505, B-Block, OT Complex, All India Institute of Medical Sciences, Patna - 801 507, Bihar
India

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Point-of-care ultrasound (POCUS) is nowadays an essential tool in pediatric critical care where other monitoring techniques may be unavailable.[1] The measurement of parameters such as diameter and calculation of the collapsibility index of major vessels, such as the inferior vena cava (IVC) and internal jugular vein (IJV), have been used to assess the hemodynamic status, and decisions regarding fluid therapy, diuresis, or ultra-filtration can be taken.[2] However, these measurements have been studied extensively, with varying results.[3] Here, we elicited the role of the left brachiocephalic vein (BCV) during the peri-operative period for the assessment of the fluid status and responsiveness to fluid therapy in a pediatric patient. Written and informed consent for publication was taken from parents.

A 10-month-old male child having a right hydronephrotic kidney was scheduled for right pyeloplasty under general anesthesia. Following induction, the patient developed one episode of hypotension. For left BCV parameters, we placed the linear ultrasound (US) probe in the left supraclavicular fossa parallel to the medial end of the clavicle with the patient in the supine position. The probe was tilted caudally to identify the venous confluence of “Pirogoff” [subclavian vein (SCV), IJV, and BCV] [Figure 1]. The effect of bolus fluid administration of 20 ml/kg is shown in [Figure 1] (panels A and B show an increase in left BCV diameter from 0.30 cm to 0.40 cm). For the measurement of the left BCV distensibility index, a US probe was applied longitudinally over the inferior portion of the IJV and venous confluence of Pirogoff was visualized. [Figure 1] (panels C and D) shows the M-mode US of the left BCV with its minimum diameter before and after bolus fluid administration of 0.42 cm and 0.59 cm, respectively, and [Figure 1] (panels E and F) shows that its maximum diameter before and after bolus fluid administration was 0.53 cm and 0.66 cm, respectively. The BCV distensibility index = [(maximum diameter on inspiration–minimum diameter on expiration)/minimum diameter on expiration], and before and after bolus fluid administration, it is 26% and 11.8%, respectively.{Figure 1}

We chose the left BCV over right because of its horizontal course. In our case, we detected a 14.2% decrease in BCV distensibility index on a fluid challenge of 20 ml/kg within 15 min [Figure 1].

POCUS assessment of fluid responsiveness in neonates and children has been reported by measuring variation of velocity–time integrals (VTIs) at the left ventricular outflow tract (LVOT) using pulse wave Doppler in apical five-chamber view.[1] A variation of >15% during inspiration and expiration has a high predictive value with the sensitivity and specificity exceeding 90%.[2] The POCUS measurement of IVC is not possible in 10–15% of patients,[3] and IJV has less sensitivity (87.5%) for the detection of hypovolemia and shock in intensive care unit patients.[2] In our large hydronephrotic kidney, obstructing the field of IVC and the IJV was fully compressed with minimal US probe pressure. The POCUS measurement of left BCV is a feasible alternative in patients where IVC or IJV and VTIs at the LVOT measurements are difficult and not practical. Further studies are required to validate our observations.

Consent

Taken from the parent.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References