Inferior Vena Cava Ultrasound: proposal for a new nursing intervention

Silva, Thiago Vital da; Teixeira, Hellen Caroline da Silva; Rodrigues, Maria Camila; Moraes, Juliana Brito de; Lopes, Juliana de Lima; Lopes, Camila Takao; Domingues, Tania Arena Moreira; Santos, Vinicius Batista

doi:10.37689/acta-ape/2025AO0002863

Abstract

Objective: To develop and analyze evidence of content validity of a nursing intervention called Inferior Vena Cava Ultrasound.

Methods: This is a methodological study divided into two phases: in the first, a narrative literature review of studies published in the previous five years was carried out, aiming to develop a new nursing intervention based on the Nursing Interventions Classification recommendations. The second phase consisted of analyzing evidence of content validity of the nursing intervention by experts on the subject in relation to clarity, theoretical relevance and practical relevance, calculating the Content Validity Ratio (CVR).

Results: Twenty-one studies were identified that addressed the inferior vena cava assessment site as well as the type of transducer, patient position and how inferior vena cava distensibility was calculated, which guided the construction of the nursing intervention Ultrasound: Inferior Vena Cava. Three rounds of assessment were necessary to achieve critical CVR, and the final intervention was made up of 19 activities and a definition, with an average time to complete it of five minutes.

Conclusion: The nursing intervention was developed based on articles published in the previous five years and presented adequate evidence of content validity. The intervention can be applied in clinical care practice and be used both in nursing teaching and research.

Resumo

Objetivo: Desenvolver e analisar as evidências de validade de conteúdo de uma intervenção de enfermagem denominada Ultrassonografia da Veia Cava Inferior.

Métodos: Estudo metodológico dividido em duas fases: na primeira, foi realizada revisão narrativa de literatura de estudos publicados nos cinco anos anteriores, visando ao desenvolvimento de uma nova intervenção de enfermagem baseada nas recomendações da Classificação das Intervenções de Enfermagem. A segunda fase consistiu na análise das evidências de validade de conteúdo da intervenção de enfermagem, por especialistas na temática, em relação à clareza, relevância teórica e pertinência prática, sendo calculada a Razão de Validade de Conteúdo (CVR).

Resultados: Identificaram-se 21 estudos que abordaram o local da avaliação da veia cava inferior, bem como o tipo de transdutor, posição do paciente e a forma do cálculo da distensibilidade da veia cava inferior, os quais nortearam a construção da intervenção de enfermagem Ultrassonografia: Veia Cava Inferior. Foram necessárias três rodadas de avaliação para o alcance da CVR crítica e a intervenção final ficou composta de 19 atividades e uma definição, com tempo médio para realização de cinco minutos.

Conclusão: a intervenção de enfermagem foi desenvolvida com base nos artigos publicados nos cinco anos prévios e apresentou adequadas evidências de validade de conteúdo. A intervenção poderá ser aplicada na prática clínica assistencial e ser utilizada tanto no ensino como na pesquisa em enfermagem.

Descritores
Ultrassonografia; Veia cava inferior; Terminologia padronizada em enfermagem; Estudos de validação

Resumen

Objetivo: Desarrollar y analizar evidencias de validez de contenido de una intervención de enfermería llamada ecografía de la vena cava inferior.

Métodos: Estudio metodológico dividido en dos fases: en la primera, se realizó una revisión narrativa de la literatura de estudios publicados en los últimos cinco años, para desarrollar una nueva intervención de enfermería basada en las recomendaciones de la Clasificación de las Intervenciones de Enfermería. La segunda fase consistió en el análisis de las evidencias de validez de contenido de la intervención de enfermería por parte de especialistas en el tema, con relación a la claridad, relevancia teórica y pertinencia práctica, y se calculó la Razón de Validez de Contenido (CVR, por sus siglas en inglés).

Resultados: Se identificaron 21 estudios que abordaron el local de evaluación de la vena cava inferior, así como el tipo de transductor, la posición del paciente y la forma del cálculo de distensibilidad de la vena cava inferior, que orientan la construcción de la intervención de enfermería: ecografía de la vena cava inferior. Fueron necesarias tres rondas de evaluación para alcanzar la CVR crítica, y la intervención final quedó compuesta por 19 actividades y una definición, con tiempo promedio de realización de cinco minutos.

Conclusion: La intervención de enfermería se desarrolló basada en los artículos publicados en los últimos cinco años y presentó evidencias de validez de contenido adecuadas. La intervención podrá aplicarse en la práctica clínica asistencial y utilizarse tanto para la enseñanza, como para la investigación de enfermería.

Descriptores
Ultrasonografía; Vena cava inferior; Terminología normalizada de enfermería; Estudio de validación

Introduction

There is a notable interest in practices capable of innovating and reforming healthcare systems, in particular, practices that improve patient safety in the face of interventions by healthcare professionals. Advanced Practice Nursing (APN) is currently considered one of these innovations, which must integrate research, education, care practice and management, providing a high degree of professional autonomy and competence in decision-making, including responsibilities in clinical case management, such as assessment, implementation and analysis of results.(¹) Worldwide, advances in the adoption of practices with technological resources aim to increase safety when carrying out procedures. In this regard, the use of ultrasound (US) by nurses represents one of the significant advances in the care provided to patients at all levels of care.

US enables several bedside procedures to be performed and contributes to improving assessment, as the fifth pillar of propaedeutics. Through the portability of current equipment, associated with team training, its implementation reduces complications and promoted patient safety.(²)

In 2021, the Federal Nursing Council approved Resolution 679, which allows nurses to perform US without nosological purposes, with this action being exclusive to nurses, within the scope of the nursing team.(³) There are several nursing procedures that can be facilitated, or even confirmed, with the use of US, such as peripheral venipuncture, peripherally inserted central catheter passage and short-term enteral catheter positioning confirmation, residual volume gastric pressure assessment before enteral diet infusion and anesthetic induction, residual urine volume assessment in the bladder and volume assessment, using the degree of collapsibility of the inferior vena cava (IVC).(⁴, ⁵)

IVC assessment through US allows assessing patients’ volume status, central venous pressure (CVP) indirectly, responsiveness to fluid therapy and the level of right ventricular preload. IVC assessment, both for monitoring diameter and collapsibility, can be performed through the subcostal window, with the convex or sector transducer in Brightness (B-mode) or Motion (M-mode) modes, with patients in supine position. An IVC diameter of less than 2.1 cm and a collapsibility greater than 50% indicate a normal CVP. An IVC diameter greater than 2.1 cm with collapsibility less than 50% indicates a high CVP value. Intermediate scenarios, in which IVC diameter and collapsibility are at intermediate values, correspond to an intermediate pressure range of 8 mmHg (5-10 mmHg).(⁶)Figure 1 shows that IVC assessment by US stands out both in B-mode and M-mode.

Figure 1
Inferior vena cava assessment in B-mode (left) and M-mode (right) by ultrasound

IVC assessment and its degree of collapsibility (patients on spontaneous ventilation) or distensibility (patients on mechanical ventilation) is an important advance in nurses’ clinical practice, as it can facilitate the identification of nursing diagnoses with greater accuracy and more assertively propose nursing interventions such as guidance for water control, referral to the emergency service, hemodynamic monitoring, energy control and hygiene and comfort care.(⁷)

This assessment, as a comprehensive part of the physical examination conducted by nurses, can be implemented in different patient care contexts. These contexts include: pre-hospital care, to assess possible bleeding; outpatient care, especially in patients at risk of fluid volume imbalance, such as those with heart failure or undergoing dialysis treatment; pre- or post-operative situations, in which there is a risk of bleeding or volume loss; emergency services or intensive care units, to assess hemodynamic and circulatory status.(⁵, ⁶, ⁸, ⁹, ¹⁰)

Given the above, the researchers of this study sought to determine whether US of IVC was included in the Nursing Interventions Classification (NIC), developed by the University of Iowa.(⁸) However, no intervention related to this specific procedure was found. Due to the recent nature of the incorporation of IVC US into nurses’ clinical practice, there is a lack of studies, both nationally and internationally, that address the performance of this assessment by nurses. Therefore, this study was designed with the purpose of filling this gap, aiming to develop and analyze evidence of content validity of a nursing intervention called Inferior Vena Cava Ultrasound.

Methods

This is a methodological study carried out in two phases: in the first, a narrative literature review was carried out focusing on identifying the stages for performing US to assess IVC diameter and distensibility for constructing intervention activities. The second phase consisted of analyzing the evidence of content validity of the proposed intervention.

Study assessment for this review was guided by the SPIDER mnemonic, with Sample being: adult patients; Phenomenon of Interest: performing US of IVC diameter and distensibility; Design: cross-sectional, longitudinal or experimental studies; Evaluation: stages to carry out US; Research type: quantitative and/or qualitative studies.

Literature search and data selection for the research was carried out in the Virtual Health Library (VHL) and in PubMed (National Library of Medicine). Studies that described the operational stages for performing US to assess IVC diameter and distensibility from 2019 to 2023 in English and Portuguese were included in this review.

The search strategies were defined and documented using the Medical Subject Headings (MeSH) and Health Sciences Descriptors (DeCS), described below:

Search 1	((ULTRASONOGRAPHY[Title/Abstract]) OR (ULTRASOUND[Title/Abstract])) AND (VENA CAVA INFERIOR[Title/Abstract])
Search 2	ultrassonografia) AND (veia cava inferior) AND (volume status) AND ( la:(“en” OR “es” OR “pt”) AND limit:(“female” OR “male” OR “middle aged” OR “adult” OR “aged”)) AND (year_cluster:[2019 TO 2023])

Initially, two researchers assessed studies for eligibility by reading their titles and abstracts, and after selecting the articles, the researchers jointly extracted information on title, year, objective, method and stages used to carry out the intervention in question, using a table created for this purpose. Both article selection and information extraction were carried out by two researchers, at the same time, in in-person meetings.

Considering the stages identified in the literature, the intervention title, definition and activities were developed based on NIC guidelines in relation to proposing new interventions.(⁷) After constructing the nursing intervention, it was submitted to content assessment by experts that were a healthcare professional (doctors, nurses or physiotherapists) with a minimum specialist qualification, with clinical and/or teaching experience in IVC US.

Eligible experts were selected using snowball sampling, with the first stratum intentionally generated from the researchers. An invitation to participate in the study was sent by email with the link to Google Forms, together with the Informed Consent Form, the expert characterization form and the instrument for assessing the intervention.

Experts assessed the intervention for clarity, theoretical relevance and practical relevance, including the intervention title, definition and activities, using a dichotomous scale, with 1 (agree) and 2 (disagree), with space for suggestions for each item assessed.

For each indicator, the Content Validity Ratio (CVR) proposed by Lawshe in 1975 was calculated. The CVR was calculated as follows: where ne means the number of experts who agreed with the item, and N, the total number of experts.(¹¹) The critical value established for the first round was 0.53 (p=0.04), considering feedback from ten experts. For the second round, the critical CVR was 0.75 (p=0.03), based on feedback from eight experts. For the third round, the critical CVR was 1.0 (p<0, 01), with the delivery of seven specialists.(¹¹)

This research was submitted to the university’s Research Ethics Committee, approved under Protocol 5.721.280 (Certificate of Presentation for Ethical Consideration (Certificado de Apresentação para Apreciação Ética) 61275922.3.0000.5505) and complied with all ethical and legal precepts.

Results

I n the first stage, 21 studies were selected that descriptively reported the performance of IVC US, excluding articles involving children, with no report on the IVC insonation technique, studies related to the development of artificial intelligence software for measuring IVC, studies that did not include adults in the assessment and review articles.

Of the 21 studies included(¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵, ²⁶, ²⁷, ²⁸, ²⁹, ³⁰, ³¹) in the review, the majority were published in 2019 and involved volume assessment using IVC US in patients with kidney disease undergoing dialysis therapy,(¹⁷, ¹⁸, ²⁰, ²⁶) heart failure,(²², ²⁸, ³¹) hospitalized with intensive care(¹⁴, ²³, ²⁵) and with bleeding in various situations, such as post-operative hip surgery,(¹⁵) vascular surgery,(²⁹) in women in the postpartum period(²⁷, ³²) and in emergency situations.(¹⁹) Studies that assessed volume status in healthy individuals were also identified.(²¹)Figure 2 shows the study selection process. Chart 1 shows the main findings.

Figure 2
Study inclusion process

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Chart 1
Articles included in the narrative literature review on the stages used in performing inferior vena cava ultrasound

Based on the narrative literature review, the first version of the nursing intervention was constructed containing 28 activities for its implementation with the title called “Ultrasound: Inferior Vena Cava,” with the following definition: Performing ultrasound to assess IVC diameter and variability in adult patients to estimate the value of CVP and volume assessment. This nursing intervention proposal was sent to 16 healthcare professionals (doctors, nurses and physiotherapists), with experience in using the US point of care, with feedback from 10 professionals. The majority of professionals were female, nurses, with a mean age of 35 years, 90% with a master’s degree, 80% with experience in standardized language system with a mean of nine years and 100% with experience in US, with mean time of five years, as shown in Table 1.

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Table 1
Expert characterization

In the first round of assessment, it was suggested that certain activities be excluded because they were not specific to the task or because they were considered routine in the institution, such as organization of materials and IVC measurement tables. Furthermore, it was recommended to group activities related to adjusting the device depth, brightness and frequency, resulting in the identification of five activities with a CVR below 0.75. The notes were reorganized and forwarded again to the group of experts for a new round of assessment with 19 activities.

Some suggestions were made by experts regarding activity description, as suggested by the NIC, i.e., replacing the expression “if possible” with “as appropriate”, summary of the technique for measuring IVC to avoid extensive description in a single activity and the form of description of IVC measurement indication. In agreement analysis, four activities had a CVR below 1.0 according to assessment by eight experts. The suggestions provided by experts were promptly incorporated by the researchers. After the necessary modifications, the document was resent for a third round of assessment to experts, with a CVR equal to 1.0 in all activities as well as title and definition. Chart 2 presents the final version of the intervention.

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Chart 2
Final version of the nursing intervention Ultrasound: Inferior Vena Cava

Discussion

The incorporation of new technologies into nurses’ clinical care practice requires that new nursing interventions be developed and subjected to assessment regarding different levels of validity evidence. In this context, this study developed a new nursing intervention to perform IVC US to measure patients’ volume status.

Volume status assessment in hospitalized patients in different settings, such as emergency hospital units, Intensive Care Units, hospitalization units with minimum and intermediate care, and also in patients treated in outpatient settings, is a constant concern, especially in critical situations, which require a detailed and specialized look from nurses. (¹², ¹³, ¹⁵, ¹⁷, ¹⁸, ¹⁹, ²⁶, ²⁹, ³¹) Therefore, IVC US is an additional tool for nurses to identify these phenomena, allowing for a more accurate assessment.(⁵)

Initially, the definition of the nursing intervention was developed based on NIC guidelines and aimed to describe the purpose of IVC US. All studies included in the narrative literature review described IVC diameter and collapsibility assessment as the main purpose of US,(¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵, ²⁶, ²⁷, ²⁸, ²⁹, ³⁰, ³¹, ³²) both for volume status assessment(¹⁷, ¹⁹, ²⁰, ²², ²⁶, ²⁸) as a means of predicting syncope(²⁹) and even anticipating arterial hypotension after tests such as colonoscopy.(¹²)

The activities included in this nursing intervention were related to the practice of patient safety(³³) and hospital infection control, such as correct patient identification, placement of personal protective equipment as well as legal prerogatives related to recording nursing actions.(³³)

An activity related to the correct choice of transducer was included, since each type of transducer for performing US has a frequency of sound waves and consequent tissue penetrability and image resolution. Therefore, based on the recommendations of studies, it was suggested to choose the convex(¹³, ¹⁴, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²⁶, ²⁹, ³²) or sectoral transducer,(²⁴, ²⁵) as they present an adequate level of tissue penetrability, capable of generate adequate image for IVC measurement.

Another activity included in the intervention was positioning patients during US. In most studies, IVC diameter was measured in patients in supine position, with the headrest tilted up to 30 degrees.(¹³, ¹⁴, ¹⁶, ¹⁹, ²⁰, ²⁶, ²⁷) In a study carried out with 95 patients hospitalized in intensive care, there was a significant difference in IVC diameter when comparing the decubitus position of 0º with the decubitus position of 45º and between 30º and 45º, with no statistical difference with the decubitus position of 0º to 30º.(²³)

The site of acquisition of IVC US image in the subxiphoid or subcostal window, with the transducer indicator facing patients’ head initially in two-dimensional mode (B-mode) and later in M-mode, was based on most of included studies, as well as measuring inspiratory and expiratory diameters, measured 2 cm from the entrance of the right atrium perpendicular to the hepatic vein.(¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵, ²⁶, ²⁷, ²⁸, ²⁹, ³⁰, ³¹, ³²)

As for the calculation of IVC variability, most studies assessed, as a method of estimating volume status, the calculation of IVC collapsibility by subtracting the maximum diameter from the minimum divided by the maximum diameter.(¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵, ²⁶, ²⁷, ²⁸, ²⁹, ³⁰, ³¹, ³²) However, it was decided to maintain the activity only by calculating the degree of IVC variability, since there are other measures that can be carried out, such as calculating fluid responsiveness, and also to maintain NIC recommendations for describing activities.

After developing the new nursing intervention, it was subjected to analysis of evidence of content validity, which refers to how relevant and representative instrument items are.(³⁴, ³⁵) The intervention was analyzed by a group of experts with notable experience in the use of US and a standardized nursing language system. This expert profile is consistent with the various current recommendations regarding analysis of evidence of content validity.(³⁴, ³⁵)

In this study, it was decided to calculate the CVR as an analysis of agreement among judges instead of choosing the Content Validity Index, as it is a calculation that reduces the risk of response bias and agreement hyperinflation,¹¹, ³⁴, ³⁵ having achieved critical CVR after the third round of assessment. The intervention was applied to five patients, with a short time to carry it out, demonstrating that it was feasible for nurses to carry it out.

The nursing intervention validated in terms of its content in this study can be used as an operational protocol to guide nurses in carrying out this intervention, as well as being used in teaching and research, aiming to use the data obtained in this US as subsidies for the identification of phenomena treatable by nursing actions.

The type of literature review carried out was considered a limitation of this study, since narrative literature review, as it does not present a systematic methodology for searching for evidence, can lead to a bias in article selection. Another limitation identified was the mean time to carry out the intervention, since this intervention was carried out by an experienced researcher, and time may be different when carried out by a professional with less training and experience.

Conclusion

The evidence identified enabled constructing the nursing intervention Ultrasound: Inferior Vena Cava, with 19 activities and a mean completion time of five minutes, having achieved adequate evidence of content validity according to experts’ assessment. This intervention can be used by nurses to assess water balance and identify causes of hemo-dynamic instability in different nurse performance scenarios.

Acknowledgements

Project funded by CNPq, Call CNPq/MCTI/FNDCT 18/2021 - Track A – Emerging Groups, Process 403285/2021-6.

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Edited by

Associate Editor
Thiago da Silva Domingos, (https://orcid.org/0000-0002-1421-7468), Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brasil

Publication Dates

Publication in this collection
28 Mar 2025
Date of issue
2025

History

Received
22 Nov 2023
Accepted
25 June 2024

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[1] ¹ Miranda Neto MV de, Rewa T, Leonello VM, Oliveira MA de C. Advanced practice nursing: a possibility for Primary Health Care? Rev Bras Enferm. 2018;71(Suppl 1):716–21.

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Country/year	Study design, objective and population	Description of the stages for measuring IVC
Turkey, 2019(¹²)	Observational and prospective study, which assessed the relationship between IVC diameter and right ventricular volume to predict hypotension after sedation for colonoscopy.	Site: subcostal window 2 to 3 cm from the right atrium entrance; Patient position: supine; Transducer: sectoral on the long axis in two-dimensional mode; Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100).
USA, 2019(¹³)	Observational and prospective study, which characterized volume status in patients with acute kidney injury and liver cirrhosis.	Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100).
Turkey, 2019(¹⁴)	Observational and prospective study, which compared the IVC collapsibility index under different values of positive pressure with CVP in patients hospitalized in an Intensive Care Unit.	Site: subxiphoid window longitudinally 3 to 4 cm distal to the junction of the IVC and the right atrium or 2 cm caudal to the junction of the IVC and the hepatic vein; Patient position: supine; Transducer: sector on the long axis in two-dimensional mode; Calculations: IVC collapsibility index [(maximum IVC - minimum IVC)/maximum IVC] × 100), distensibility: [(maximum IVC – minimum IVC)/minimum IVC] × 100 and delta: [(maximum IVC - IVC minimum)/IVC median] × 100).
Turkey, 2019(¹⁵)	Observational and prospective study, which assessed the relationship between IVC measurements and the value of urea and creatinine in patients undergoing hip fracture surgery.	Site: subcostal window 2 to 3 cm from the entrance to the right atrium; Patient position: supine; Transducer: low frequency convex along the longitudinal axis; Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100). Time to perform: 10 minutes.
Italy, 2019(¹⁶)	Intervention study of an algorithm that assessed the value of right atrial pressure with anthropometric and US data in patients undergoing right heart catheterization and echocardiography.	Site: subcostal window 2 to 3 cm from the entrance to the right atrium; Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100).
Poland, 2019(¹⁷)	Observational and prospective study, which assessed the relationship between left ventricular dysfunction, pulmonary hypertension and hypervolemia in patients with chronic kidney disease undergoing dialysis therapy.	Site: subcostal window 2 to 3 cm from the entrance to the right atrium; Patient position: supine; Transducer: 3.5 MHz convex transducer.
Australia, 2019(¹⁸)	Observational and prospective study, which assessed the pre-dialysis accuracy of fluids in patients during dialysis therapy.	Site: subcostal window 2 to 3 cm from the entrance to the right atrium; Patient position: supine; Transducer: convex; Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100).
Spain, 2019(¹⁹)	Observational and prospective study, which assessed the usefulness of hemodynamic monitoring by IVC US before and after passive lower limb augmentation in patients in the emergency department with a history of upper and lower gastrointestinal bleeding.	Site: subcostal window 2 to 3 cm from the entrance to the right atrium; Transducer: convex along the longitudinal axis; Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100).
Egypt, 2020(²⁰)	Prospective cohort study, which assessed the use of US in volume assessment in hemodialysis patients in comparison with clinical signs and IVC diameter and its relationship with volume loss after ultrafiltration.	Site: subcostal window 2 to 3 cm from the entrance to the right atrium; Patient position: supine; Transducer: low-frequency convex along the longitudinal axis; Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100).
Turkey, 2020(²¹)	Observational and prospective study, which assessed the value of combined use of IVC diameter and abdominal aorta diameter in monitoring blood loss in healthy people and blood donation volunteers.	Site: 2 cm subcostal window caudal to the junction of the hepatic vein and IVC. Patient position: supine; Transducer: convex along the longitudinal axis; Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100).
USA, 2020(²²)	Observational and prospective study, which assessed the clinical correlation of volume status in decompensated heart failure.	Site: subxiphoid window; Patient position: supine; Transducer: low-frequency convex along the longitudinal axis; Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100).
USA, 2020(²³)	Observational and prospective study, which assessed whether IVC diameter measurements would be affected by decubitus position elevation and to study the effect that decubitus position elevation would have on IVC diameter in patients in Intensive Care Unit.	Site: point immediately distal to the hepatic vein using a two-dimensional mode with a sector transducer.
England, 2020(²⁴)	Observational and prospective study, which assessed the accuracy of five non-invasive methods in detecting fluid responsiveness in the emergency room in patients requiring fluid resuscitation.	Site: subcostal window 1 cm distal to the hepatic vein junction; Patient position: supine; Transducer: low frequency convex; Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100).
Turkey, 2021(²⁵)	Observational and prospective study, which compared different ventilation parameters with IVC diameter and echocardiographic data in sedated patients undergoing mechanical ventilation.	Site: 1 cm from the junction of the hepatic-caval region using M-mode image in the longitudinal view in the subcostal window; Transducer: convex along the longitudinal axis; Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100).
Slovenia, 2021(²⁶)	Observational and prospective study, which assessed different methods of assessing volume status and its association with arterial stiffness parameters in patients on peritoneal dialysis.	Site: subxiphoid window 0.5 to 3 cm caudal to the right of the atrial junction; Patient position: supine; Transducer: sector; Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100).
Israel, 2022(²⁷)	Case-control study assessing whether IVC diameter is a useful marker in assessing intravascular volume status in women with postpartum hemorrhage.	Site: subxiphoid window; Position: supine position; Transducer: convex from 2 to 5.5 MHz; Calculations: The difference between eIVC and iIVC diameters was then divided by eIVC diameter and multiplied by 100 to calculate the collapsibility index.
USA, 2022(²⁸)	Observational and prospective study, which compared IVC and the right jugular vein with the right atrial pressure measurement in adult patients with heart failure.	Site: epigastric area. The IVC was measured 1 to 2 cm from the junction of the IVC with the right atrium at the end of expiration; Patient position: supine.
Uruguay, 2022(²⁹)	Observational and prospective study, which assessed the relationship between IVC diameter and CVP and intravascular volume status assessment in patients undergoing vascular surgery.	Calculations: IVC diameter measurements were recorded in both the end-inspiratory and end-expiratory phases.
Turkey, 2023(³⁰)	Observational and US study assessing a whole-body US protocol to recognize patients at high risk for syncope.	Site: subxiphoid window in a long-axis configuration along the IVC at the junction of the right atrium 2 to 3 cm caudal along the vessel by M-mode; Transducer: convex or sector; Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100).
Spain, 2023(³¹)	Observational and prospective study, which assessed the common femoral vein pulsed ultrasound doppler in IVC dilation assessment in patients with decompensated heart failure.	Site: 2 cm at the entrance to the right atrium at the end of expiration.
China, 2023(³²)	Prospective cohort study, which assessed the value of IVC and IVC collapsibility index in monitoring volume status during treatment of postpartum hemorrhage.	Site: subxiphoid region 1 to 2 cm caudal to the entrance of the hepatic vein. The IVC was measured at the proximal end of the confluence of the hepatic veins perpendicular to its long axis; Transducer: convex; Calculations: collapsibility index (difference between maximum and minimum diameters divided by maximum diameter x 100).

Variables	Measure
Age, mean (SD)	35.8 (5.92)
Female, n (%)	6 (60)
Academic training, n (%)
Nursing	8 (80)
Medicine	1(10)
Physiotherapy	1 (10)
Highest degree, n (%)
Doctoral degree	1 (10)
Master’s degree	9 (90)
Experience in Nursing Classification System, n (%) *	8 (80)
Teaching	4 (40)
Research	2 (20)
Care	6 (60)
Experience in nursing classifications, n (%)*	9.8 (6.7)
Experience in ultrasound, n (%)	10 (100)
Teaching	3 (30)
Research	1 (10)
Care	7 (70)
Length of experience in ultrasound, Med (Q1;Q3)	4.0 (2.0;6.0)

Title	Ultrasound: Inferior Vena Cava
Performing ultrasound to assess inferior vena cava diameter and distensibility.
1.	Assess clinical indication for performing inferior vena cava ultrasound to determine volume status, the approximate central venous pressure (CVP), the possible cause of hemodynamic instability and response to volume therapy
2.	Identify patient according to institutional protocol and guide them regarding the suggested procedure
3.	Instruct patient and family about the indications for the exam, purpose and limitations
4.	Select the convex or sector transducer (phased array) to perform the procedure
5.	Put on personal protective equipment according to institutional protocol
6.	Position patient in supine position, preferably without inclination, as appropriate
7.	Adjust the ultrasound device for better image acquisition in terms of depth, brightness and focus, as appropriate
8.	Position the transducer in a longitudinal position in the subxiphoid window with the transducer orientation marker facing the patient’s head and slightly tilted to the patient’s right
9.	Identify the junction of the inferior vena cava with the right atrium in two-dimensional brightness mode (B-mode) or M-mode
10.	Ask patient to inhale and freeze the image in two-dimensional brightness mode (B mode)
11.	Measure vena cava diameter less than 2 cm from the entrance to the right atrium, perpendicular to the entrance of the hepatic vein in two-dimensional brightness mode (B mode) or M-mode
12.	Instruct patient to breathe normally between image captures, as appropriate.
13.	Ask patient to perform a maximum exhalation and freeze the image in two-dimensional brightness mode (B-mode) or M mode
14.	Measure vena cava diameter less than 2 cm from the entrance to the right atrium perpendicular to the entrance to the hepatic vein in two-dimensional brightness mode (B-mode)
15.	Instruct the patient to breathe normally between image captures, as appropriate
16.	Calculate the degree of inferior vena cava distensibility
17.	Assist or remove excess gel from patient’s skin
18.	Reposition the patient in bed after the exam, as appropriate
19.	Record the examination findings in patient’s medical record