Changes in BP Induced by Passive Leg Raising Predict Response to Fluid Loading in Critically Ill Patients

doi:10.1378/chest.121.4.1245

Chest

Volume 121, Issue 4, April 2002, Pages 1245-1252

https://doi.org/10.1378/chest.121.4.1245 Get rights and content

Objective

To test the hypothesis that passive leg raising (PLR) induces changes in arterial pulse pressure that can help to predict the response to rapid fluid loading (RFL) in patients with acute circulatory failure who are receiving mechanical ventilation.

Design

Prospective clinical study.

Setting

Two medical ICUs in university hospitals.

Patients

Thirty-nine patients with acute circulatory failure who were receiving mechanical ventilation and had a pulmonary artery catheter in place.

Interventions

PLR for > 4 min and a subsequent 300-mL RFL for > 20 min.

Measurements and main results

Radial artery pulse pressure (PPrad), heart rate, right atrial pressure, pulmonary artery occlusion pressure (PAOP), and cardiac output were measured invasively in a population of 15 patients at each phase of the study procedure (ie, before and during PLR, and then before and after RFL). PPrad, PAOP, and stroke volume (SV) significantly increased in patients performing PLR. These changes were rapidly reversible when the patients' legs were lowered. Changes in PPrad during PLR were significantly correlated with changes in SV during PLR (r = 0.77; p < 0.001). Changes in SV induced by PLR and by RFL were significantly correlated (r = 0.89; p < 0.001). Finally, PLR-induced changes in PPrad were significantly correlated to RFL-induced changes in SV (r = 0.84; p < 0.001). In a second population of 24 patients, we found the same relationship between PLR-induced changes in PPrad and RFL-induced changes in SV (r = 0.73; p < 0.001).

Conclusion

The response to RFL could be predicted noninvasively by a simple observation of changes in pulse pressure during PLR in patients with acute circulatory failure who were receiving mechanical ventilation.

Section snippets

Materials and Methods

We first studied 15 consecutive patients who were admitted to the ICU for acute circulatory failure, which was defined as a systolic arterial pressure (SAP) < 90 mm Hg (or a decrease of > 50 mm Hg in previously hypertensive patients) and urine output of < 0.5 mL/kg/min for at least 2 h. All patients were receiving mechanical ventilation in a volume-controlled mode. Positive end-expiratory pressure was used in two patients and did not exceed 8 cm H₂O. All patients were studied within the first 3

Results

The clinical characteristics of the patients studied are listed in Table 1.

Analysis of variance detected significant changes in BP that were induced by PLR positioning, by the return of the legs to the supine position, and by RFL, while it detected no change in BP values recorded within each phase of the procedure. Because of the stability of BP (ie, SAP, DAP, and MAP) within each phase of the PLR and RFL procedures, we expressed individual BP values as the average of the four measurements

Discussion

The main finding of our study was that changes in PPrad induced by PLR are proportional to the changes in SV that are obtained with a subsequent RFL. Therefore, simple measurements of BP during PLR could help to detect patients who will positively respond to volume expansion.

Conclusion

Our data suggest that in patients with acute circulatory failure who are receiving mechanical ventilation, the hemodynamic response to fluid loading could be predicted by simply measuring arterial pulse pressure changes during PLR. This may have two practical implications: (1) the existence of a cardiac preload dependence could be detected without the use of a Swan-Ganz catheter; and (2) a potentially harmful fluid-loading procedure could be avoided when unnecessary.

ACKNOWLEDGMENT

We thank Dr. Denis Chemla (Le Kremlin-Bicetre) for his helpful comments.

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Cited by (261)

A critical review of the hemodynamics in assessment of volume responsiveness by using passive leg raising (PLR)
2023, Trends in Anaesthesia and Critical Care
The monitoring and regulation of cardiovascular function are increasingly based on dynamic indices. The aim of the present review is to scrutinize the history, physiological foundation, development, statistical apparatus and clinical impact on morbidity and mortality of one of the maneuvers leading to a dynamic index of fluid responsiveness, viz. the passive leg raising.
Tracing the development of PLR from the early 80-ies revealed contrasting and irreconcilable perceptions of physiological mechanism in PLR and an increasing consensus on the formalities in analyzing results of validation studies in terms of ROC analysis, gray zones and Bayesian statistics resulting in the demonstration of good ability of PLR to predict volume responsiveness in an experimental setting. The impact on decreased morbidity and mortality, however, is absent in clinical trials involving PLR vs normal care.
The passive leg raising manoeuvre is lacking in a consistent physiological modelling of the cardiovascular system, the purpose of the manoeuvre is ill-defined, the execution and timing are unclear and monitoring in the longer term leaves much to be desired. This serves to corroborate that the manoeuvre so far hasn’t demonstrated a significant benefit in terms of survival in a clinical context. A call for an alternative approach is presented.
Venom Hypersensitivity
2023, Primary Care - Clinics in Office Practice
Passive Leg Raise Stress Echocardiography in Severe Paradoxical Low-Flow, Low-Gradient Aortic Stenosis
2022, Journal of the American Society of Echocardiography
Dobutamine stress echocardiography is used to increase transvalvular flow in patients with low-flow, low-gradient aortic stenosis (AS). Dobutamine fails to increase the stroke volume index (SVI) in one third of patients. The aim of this study was to test whether passive leg raise (PLR) added to dobutamine could increase SVI and transvalvular flow in patients with severe paradoxical low-flow, low-gradient AS.
Forty-five patients with apparent severe low-flow, low-gradient AS on the basis of traditional measurements were included. Twenty-five were categorized as belonging to the paradox group (left ventricular ejection fraction [EF] ≥ 50%) and 20 to the low EF group (left ventricular EF < 50% or “classical” low-flow, low-gradient AS) for comparison. A four-step stress echocardiographic examination was performed: resting conditions (rest), PLR alone (PLR), maximal dobutamine infusion rate (Dmax), and a combination of Dmax and PLR (Dmax+PLR). Aortic valve area, SVI, and mean transvalvular flow were calculated using both the velocity-time integral (VTI) of left ventricular outflow tract and the Simpson method. Changes compared with rest and between the stress maneuvers were analyzed.
In the paradox group, compared with rest, left ventricular end-diastolic volume was significantly decreased with Dmax but was completely restored with Dmax+PLR (rest vs Dmax vs Dmax+PLR: 61 ± 15 vs 49 ± 18 mL [P < .001] vs 61 ± 18 mL [P = NS]). The smallest increase in SVI in the paradox group was observed during Dmax (PLR vs Dmax vs Dmax+PLR: VTI, 38 ± 4 mL/m² [P < .001] vs 36 ± 7 mL/m² [P = .019] vs 41 ± 7 mL/m² [P < .001]; Simpson, 28 ± 6 mL/m² [P < .001], 21 ± 7 mL/m² [P = NS], 27 ± 7 mL/m² [P = NS]). Compared with Dmax, Dmax+PLR was able to achieve a higher SVI (VTI, 36 ± 7 vs 41 ± 7 mL/m² [P < .001]; Simpson, 21 ± 7 vs 27 ± 7 mL/m² [P < .001]) and transvalvular flow with the Simpson method only (179 ± 56 vs 219 ± 56 mL/sec, P < .001), as well as a higher mean gradient (34 ± 10 vs 39 ± 12 mm Hg, P = .003) and AVA with the Simpson method (0.64 ± 0.21 vs 0.73 ± 0.21 cm², P = .026). In the low EF group, only SVI VTI (31 ± 8 vs 35 ± 7 mL/m², P = .034) and mean gradient (29 ± 12 vs 34 ± 14 mm Hg, P = .003) were higher with Dmax+PLR. The proportion of patients with SVI VTI ≥ 35 mL/m² and increases of SVI VTI of >20% compared with rest was highest with Dmax+PLR in both groups.
Dobutamine decreases preload in paradoxical low-flow, low-gradient AS. Adding PLR counteracts this effect, resulting in increased SVI and flow (in one method). The combined stress maneuver allowed reclassification of some patients from severe to moderate AS and may therefore be useful in selected cases in this population in which severity is uncertain.
Passive leg raising-induced changes in pulse pressure variation to assess fluid responsiveness in mechanically ventilated patients: a multicentre prospective observational study
2022, British Journal of Anaesthesia
Passive leg raising-induced changes in cardiac index can be used to predict fluid responsiveness. We investigated whether passive leg raising-induced changes in pulse pressure variation (ΔPPV_PLR) can also predict fluid responsiveness in mechanically ventilated patients.
In this multicentre prospective observational study, we included 270 critically ill patients on mechanical ventilation in whom volume expansion was indicated because of acute circulatory failure. We did not include patients with cardiac arrythmias. Cardiac index and PPV were measured before/during a passive leg raising test and before/after volume expansion. A volume expansion-induced increase in cardiac index of >15% defined fluid responsiveness. To investigate whether ΔPPV_PLR can predict fluid responsiveness, we determined areas under the receiver operating characteristic curves (AUROCs) and grey zones for relative and absolute ΔPPV_PLR.
Of the 270 patients, 238 (88%) were on controlled mechanical ventilation with no spontaneous breathing activity and 32 (12%) were on pressure support ventilation. The median tidal volume was 7.1 (inter-quartile range [IQR], 6.6–7.6) ml kg⁻¹ ideal body weight. One hundred sixty-four patients (61%) were fluid responders. Relative and absolute ΔPPV_PLR predicted fluid responsiveness with an AUROC of 0.92 (95% confidence interval [95% CI], 0.88–0.95; P<0.001) each. The grey zone for relative and absolute ΔPPV_PLR included 4.8% and 22.6% of patients, respectively. These results were not affected by ventilatory mode and baseline characteristics (type of shock, centre, vasoactive treatment).
Passive leg raising-induced changes in pulse pressure variation accurately predict fluid responsiveness with a small grey zone in critically ill patients on mechanical ventilation.
NCT 03225378.
Variation of Left Ventricular Outflow Tract Velocity Time Integral at Different Positive End-Expiratory Pressure Levels Can Predict Fluid Responsiveness in Mechanically Ventilated Critically Ill Patients
2022, Journal of Cardiothoracic and Vascular Anesthesia
To explore whether the variation of left ventricular outflow tract velocity time integral (LVOT VTI) between positive end-expiratory pressure (PEEP) 10 cmH₂O and PEEP 0 cmH₂O can predict fluid responsiveness in mechanically ventilated critically ill patients.
An observational study.
A tertiary hospital intensive care unit.
A total of 79 critically ill patients who were on controlled mechanical ventilation.
Transthoracic echocardiography was performed at different PEEP levels and was also performed before and after passive leg raising (PLR).
The patients were classified as the fluid responders (n = 45) and the fluid nonresponders (n = 34) according to the LVOT VTI change after PLR (ΔVTI_PLR). The difference of LVOT VTI between PEEP 10 cmH₂O and PEEP 0 cmH₂O (ΔVTI_PEEP) was much higher in responders than in nonresponders (17.9% v 2.1%, p < 0.001). The ΔVTI_PEEP and ΔVTI_PLR were correlated among all patients (r = 0.582, p < 0.001). The receiver operating characteristic curve analysis revealed that the ΔVTI_PEEP was a good predictor of fluid responsiveness, with an area under the curve of 0.935 (95% confidence interval: 0.885-0.986, p < 0.001), and the optimal cutoff value was 10.5%.
Variation of LVOT VTI between PEEP 10 cmH₂O and PEEP 0 cmH₂O can be used to predict fluid responsiveness in critically ill patients on controlled mechanical ventilation.
Value of DYnamicVariation of impedance cardiac output in the diagnosis of heart failure in emergency department patients with undifferentiated dyspnea.
2021, American Journal of Emergency Medicine
Cardiac output (CO) responses to acute changes in body position and Valsalva maneuver (VM) were proposed to assess cardiac contractile reserve. We investigated the value of sitting position (SP), leg raising (LR), and VM for identifying heart failure (HF) in patients with undifferentiated dyspnea.
It is a prospective study including patients over 18 years old admitted to the emergency department (ED) for dyspnea. Bioimpedance CO was measured at baseline, under SP, LR, and VM. HF diagnosis was based on clinical assessment, serum levels of brain natriuretic peptide (BNP) and echocardiography findings. Study population was divided into patients with heart failure (HF group) and patients without HF (HF- group). Diagnostic performance of CO change under the three maneuvers was calculated by sensitivity, specificity, likelihood ratio and receiver operating characteristic (ROC) curve.
290 patients were enrolled in the study. The final diagnosis was dyspnea due to congestive heart failure in 147 patients (50.7%). CO change with VM was the most accurate exam in identifying congestive heart failure as the cause of dyspnea with a sensitivity, specificity, positive and negative likelihood ratios of 79%, 60%, 1.97, and 0.36 respectively. Area under ROC curve was 0.62(95% CI, 0.55–0.69), 0.63(95% CI, 0.56–0.69), and 0.70(95% CI, 0.64–0.76) respectively for SP, LR, and VM. In a multivariate analysis, CO change with VM, but not with SP or LR, carried independent diagnostic value (p < 0.001).
the diagnosis of HF can be aided with use of analyzing the effect of VM on non-invasively measured CO among patients admitted to the ED with undifferentiated dyspnea. Diagnostic yield of SP and LR was poor.

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View full text

Chest

Clinical Investigations in Critical CareChanges in BP Induced by Passive Leg Raising Predict Response to Fluid Loading in Critically Ill Patients

Objective

Design

Setting

Patients

Interventions

Measurements and main results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Conclusion

ACKNOWLEDGMENT

Am Heart J

Am J Med

Chest

Reliability of clinical monitoring to assess blood volume in critically ill patients

Crit Care Med

Radionuclide assessment of peripheral intravascular capacity: a technique to measure intravascular volumes changes in the capacitance circulation in man

Circulation

Trendelenburg position and passive leg raising do not significantly improve cardiopulmonary performance in the anesthetized patient with coronary artery disease

Crit Care Med

The circulatory response to a standard postural change in ischaemic heart disease

Br Heart J

Nitroglycerin-induced decrease of carbon monoxide diffusion capacity in acute myocardial infarction reversed by elevating legs

Crit Care Med

Acute cardiovascular response to passive leg raising

Crit Care Med

Changes in cardiac output after acute blood loss and position change in man

Crit Care Med

Oxygen consumption and transport in stable patients with chronic obstructive pulmonary disease

Am Rev Respir Dis

Total arterial compliance estimated by stroke volume-to-aortic pulse pressure ratio in humans

Am J Physiol

Controlled sedation with alpharealone-alphadalone

BMJ

Passive leg raising does not produce a significant or sustained autotransfusion effect

J Trauma

Clinical Investigations in Critical Care
Changes in BP Induced by Passive Leg Raising Predict Response to Fluid Loading in Critically Ill Patients