EJV Occlusion Pressure Measurement to Assess Intravascular Volume in Cirrhotic Patients During IV Albumin Substitution

Cirrhotic patients with portal hypertension are prone to develop ascites. Current guidelines recommend volume expansion using intravenous (IV) albumin infusion for several circumstances, such as large volume paracentesis, development of spontaneous bacterial peritonitis (SBP), and treatment of acute kidney injury (AKI) with/without hepatorenal syndrome (HRS). However, current dosages for IV albumin infusion do not consider individual intravascular volume status before its administration. In addition, there are increasing reports of volume overload following volume expansion with albumin in cirrhotic patients within and beyond current indications. Non-invasive point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) diameter and collapsibility index (IVCCI) using echocardiography has been proposed for assessing volume status in patients with cardiac disease and for predicting fluid responsiveness in critically ill patients. In addition, determining the occlusion pressure of the external jugular vein (EJV) has been proposed as a surrogate parameter for the estimation of central venous pressure (CVP). In 2005, Baumann et al. introduced a novel method for non-invasive venous pressure measurement by combining ultrasound and a tissue pressure manometer. Peripheral occlusion pressure was measured non-invasively via jugular and basilic vein. Although good correlation with invasive CVP measurements was achieved and measurements showed potential to reflect patients' 'tolerable reserve' with respect to fluid-overload in intensive care and cardiologic patients, its application in cirrhotic patients needs to be studied.

In this study, the investigators aim to assess whether compression of the EJV is feasible in the cirrhotic patients population and observe the change in EJV occlusion pressure determined by the CPMX2 in parallel to sonographic assessment of the IVC diameters and IVCCI as indicators for changes in intravascular volume status in patients with decompensated cirrhosis and an indication for intravenous albumin substitution.

The objective of this clinical investigation is to assess safety and feasibility of external jugular vein (EJV) occlusion pressure measured non-invasively with CPMX2 in patients with decompensated cirrhosis with an indication for albumin infusion.

Data gathered in this study will help define hypotheses to be used in future clinical investigations about the role of absolute values and/or changes in EJV occlusion pressure in characterizing intravascular volume status and its change after passive leg elevation (as an indirect test for fluid responsiveness) and intravenous albumin infusion (for volume expansion) in patients with decompensated cirrhosis.

Inclusion criteria

• In- and outpatients with liver cirrhosis of any etiology, diagnosed by either liver histology or compatible biochemical, imaging and clinical parameters, being treated at the department of Visceral Surgery and Medicine at Inselspital Bern, University Hospital Bern, Switzerland.
• Age ≥ 18 years
• Indication for IV albumin infusion according to current EASL guidelines[11] and BAVENO VII consensus recommendations[12] including large volume paracentesis, spontaneous bacterial peritonitis (SBP), AKI with/without HRS.
• Available transthoracic echocardiography assessing right heart function within maximum 3 months from study inclusion.

Exclusion criteria

• Patients admitted to intermediate care unit or intensive care unit at the time of albumin infusion
• Previous IV albumin infusion within the last 5 days
• Contraindication to the PLR test (i.e. increased intracranial pressure)
• Contraindication to albumin infusion (i.e. anaphylactic reactions against albumin)
• History of right heart failure
• Clinical evidence of lung edema, hemodynamic instability/shock
• Anatomic IVC abnormalities, such as IVC stenosis and/or thrombosis
• History of orthotopic liver transplant
• Patients unable to provide informed consent