Cheetah Medi cal

TM
www.cheetahnicom.com
PASSIVE LEG RAISE (PLR) TEST
Estimation of Fluid Responsiveness
45
Stroke Volume Index (SVI)
First Step Baseline
Second Step Challenge
30-45
*
Fluid Responsive: SVI will increase by >15% in response to 500 mL IV uid
administration
Test is positive: SVI rise ) 10% ; Patient is Fluid Responsive
Test is negative: SVI rise < 10% ; Patient is not Fluid Responsive
Obtain 3 readings (equals to 3 minutes). In uid responsive
*

patients look for the following anticipated stroke volume index
response:
Obtain 3 readings (equals to 3 minutes)
See references on back
Patient position: Lying in a semi-recumbent position
Patient position: Passive leg raise (about 30-45 degrees)
SVI ) 10%
NICOM Sensors should be replaced with a new set of sensors after 48 hours of use.
Remember to perform a re-calibration after sensor replacement and once daily.
Code: M-PLR Rev. 07 August 13, 2012
REFERENCES
Benhomar B, Outattara A, Brusset A, et al. Use of transthoracic Bioreactance during
passive leg raise test to determine uid Responsiveness. European Society of Intensive
Care Medicine, 2009
Bioreactance-based CO assessment is a sensitive and specic method for assessing uid
responsiveness. The high precision and responsiveness of this tool enable using a low
threshold of 5% PLR response, in a quick time frame of 3 min. following PLR. The sensitivity
and specicity to predict a 10% increase in CO following 500 mL bolus infusion are 93%
and 71%, respectively.
Meaning: Bioreactance in conjunction with a PLR is highly sensitive and specic to detect
uid responsiveness. The technology is responsive and precise enough to provide a
directional reading after just 3 minutes of challenge.
1. to predict the hemodynamic response to a uid challenge. CVP should not be used to make
clinical decisions regarding uid management.
Meaning: Measurements of venous pressures (CVP) should not be used to make decisions
on uid management.
Marik PE, Baram M, Vahid B, et al. Does Central Venous Pressure Predict Fluid
Responsiveness? A Systematic Review of the Literature and the Tale of Seven Mares.
Chest 2008; 134:172178
A systematic review of the literature to determine: (1) relationship between CVP and blood
volume, (2) ability of CVP to predict uid responsiveness, and (3) ability of the change in CVP
([CVP) to predict uid responsiveness The pooled correlation coefcient between baseline
CVP and change in stroke index/cardiac index was 0.18 (95% CI, 0.08 to 0.28). The pooled
correlation between [CVP and change in stroke index/cardiac index was 0.11 (95% CI, 0.015
to 0.21). Baseline CVP was 8.7 2.32 mm Hg [mean SD] in the responders as compared to
9.7 2.2 mm Hg in nonresponders (not signicant). This systematic review demonstrated a
very poor relationship between CVP and blood volume as well as the inability of CVP/[CVP
6.
Lamia B, Cuvelier A, Declercq PL, et al. Response of NICOM stroke volume to passive leg
raising to predict uid responsiveness in critically ill patients with spontaneous breathing
activity. International Symposium on Intensive Care and Emergency Medicine, 2010
Our objective was to test whether volume responsiveness could be predicted by the
response of stroke volume measured by the NCOM device to passive leg raising (PLR) in
patients with spontaneous breathing activity. Methods: Prospective study in the respiratory
critical care of a university hospital. Patients: 11 patients with spontaneously breathing activity
considered for volume expansion. An increase in stroke volume index (SVi) of 15% or more
after volume expansion dened a responder patient. We measured the response of the
Bioreactance stroke volume to passive leg raising and to saline infusion (500 ml over 15 min).
Results: The proportional changes in NiCOM-SVi induced by PLR were correlated with the
proportional changes in NICOM-SVi induced by volume expansion (r= 0.67, p=0.02). The
proportional changes in NICOM-cardiac index (CI) induced by PLR were also correlated with
the proportional changes in NICOM-CI induced by volume expansion (r= 0.63, p= 0.03). A
passive leg raising induced increase in stroke volume of 9% or more predicted an increase in
stroke volume of 15% or more after volume expansion with a sensitivity of 100% and a
specicity of 80%. Conclusions: The response of NICOM-stroke volume to passive leg raising
was a good predictor of volume responsiveness. In our hemodynamically unstable patients
with spontaneous breathing activity, uid responsiveness can be assessed totally non-invasively
with a bioreactance device.
Meaning: As in Benhomar et al.
2.
Cavallaro F, Sandroni C, Marano C, et al. Diagnostic accuracy of passi ve leg raising for
prediction of flui d responsi veness in adults: systematic revi ew and meta-analysis of
clinical studies. Intensi ve Care Med. 2010; 36(9):1475-1483
Passive leg raising-induced changes in cardiac output reliably predict uid responsiveness
regardless of ventilation mode, underlying cardiac rhythm and technique of measurement
and can be recommended for routine assessment of uid responsiveness in the majority of
ICU population.
Meaning: Speaks for itself.
3.
Maizel J, Airapetian N, Lorne E, et al. Diagnosis of central hypovolemia by using passive
leg raising. Intensive Care Med 2007; 33: 1133 1138
"This prospective study was performed in four intensive care units This study shows that
changes in CO or SV during PLR (passive leg raise) are predictive of central hypovolemia.
An increase by more than 12% of cardiac output or SV during PLR was predictive of a positive
hemodynamic response after fluid expansion. In spontaneously breathing patients with
suspected hypovolemia, cardiac output or stroke volume measurement using echocardiography
during passive leg raising can very accurately discriminate patients who will obtain a
hemodynamic benet from fluid challenge.
Meaning: In ICU patients a positive PLR test done by echo helps guide fluid management.
Potential implication: While echo is intermittent, expensive and requires a high skilled
clinician to perform, a NICOM PLR can be performed by the nurse quickly and in
cost-effective fashion on a large volume of patients.
4.
Monnet X, Teboul JL. Passive leg raising. Intensive Care Med 2008; 34:659-63
"Predicting fluid responsiveness solely on the basis of measures of preload must be discouraged.
In this regard cardiac lling pressures such as central venous pressure and pulmonary artery
occlusion pressure cannot differentiate between patients responding and patients not responding
to fluid administration. Fluid responsiveness assessment must be rather based on the response
to dynamic tests which induce transient changes in cardiac preload. The physiological effects
of PLR consist of an increase in venous return and cardiac preload. The PLR thus acts as a
self-volume challenge which is easy to-perform and completely reversible. It has gained an
increasing interest in the eld of functional hemodynamic monitoring. PLR test should be
increasingly used at the bedside since it is easy to perform and effective, provided that its
effects are assessed by a real-time measurement of cardiac output. The optimal use of PLR
requires a real-time cardiovascular assessment device able to quantify accurately the short-term
hemodynamic response.
Meaning: Speaks for itself.
7.
Prau S, Saulnier F, Dewavrin F, et al. Passive leg raising is predictive of uid responsiveness
in spontaneously breathing patients with severe sepsis or acute pancreatitis. Crit Care
Med. 2010;38(3):819-25
"Rapid uid loading is standard treatment for hypovolemia. Because volume expansion does
not always improve hemodynamic status, predictive parameters of uid responsiveness are
needed... Passive leg raising-induced changes in stroke volume and its surrogates are reliable
predictive indices of volume expansion responsiveness for mechanically ventilated patients.
We hypothesized that the hemodynamic response to passive leg raising indicates uid
responsiveness in nonintubated patients without mechanical ventilation... Patients: We
investigated consecutive nonintubated patients, without mechanical ventilation, considered
for volume expansion. Interventions: We assessed hemodynamic status at baseline, after
passive leg raising, and after volume expansion (500 mL 6% hydroxyethyl starch infusion over
30 mins). Results: ...All patients included in the study had severe sepsis (n = 28; 82%) or
acute pancreatitis (n = 6; 18%). The Deltastroke volume >or=10% predicted uid responsiveness
with sensitivity of 86% and specicity of 90%. The Deltapulse pressure >or=9% predicted
uid responsiveness with sensitivity of 79% and specicity of 85%. The Deltavelocity of
femoral artery ow >or=8% predicted uid responsiveness with sensitivity of 86% and
specicity of 80%. Conclusions: Changes in stroke volume... induced by passive leg raising
are accurate and interchangeable indices for predicting uid responsiveness in nonintubated
patients with severe sepsis or acute pancreatitis.
Meaning: Measurement of the Stroke Volume response to PLR is highly sensitive and
specic in spontaneously breathing patients suffering from severe sepsis and acute
pancreatitis.
8.
Marik P, Monnet X, Teboul JL. Hemodynamic parameters to guide uid therapy. Ann
Intensive Care, 2011;1:1
"It should be appreciated that both arrhythmias and spontaneous breathing activity will lead
to misinterpretations of the respiratory variations in pulse pressure/ stroke volume. Furthermore,
for any specic preload condition the PPV/SVV will vary according to the tidal volume The
change in aortic blood flow (measured by esophageal Doppler) during a 45 leg elevation was
shown to predict the changes in aortic blood flow produced by a 500-mL fluid challenge even
in patients with cardiac arrhythmias and/or spontaneous ventilator triggering, situations in
which PPV lost its predictive ability. A recent meta-analysis, which pooled the results of eight
recent studies, confirmed the excellent value of PLR to predict fluid responsiveness in critically
ill patients with a global area under the receiver operating characteristic curve of 0.95 In
the initial stages of resuscitation in the emergency room, ward, or ICU, most patients are not
intubated and are breathing spontaneously. In addition, with the reduced use of sedative
agents in the ICU, many critically ill patients are ventilated with modes of ventilation that
allow spontaneous breathing activity. Because the respiratory variability of hemodynamic
signals cannot be used for predicting volume responsiveness in spontaneously breathing
patients, other techniques, such as passive leg raising (PLR), have been proposed for this
purpose The cardiac output as measured by bioreactance has been shown to be highly
correlated with that measured by thermodilution and pulse contour analysis. In a cohort of
patients after elective cardiac surgery, Benomar and coauthors demonstrated that the
NICOM system could accurately predict fluid responsiveness from changes in cardiac output
during PLR. The NICOM system has an algorithm with user prompts and an interface that
rapidly facilitates the performance of a PLR maneuver. Although the dynamic changes of the
plethysmographic waveform have been demonstrated to be predictive of volume responsiveness
in ventilated patients, this technology is poorly predictive of volume responsiveness in
spontaneously breathing persons after a PLR challenge. The hemodynamic effects of PLR must
be assessed by a direct measure of cardiac output or stroke volume; assessing the PLR effects
solely on the arterial pulse pressure leads to a signicant number of false-negative cases. This
suggests that in spontaneously breathing patients, pulse pressure is not of sufficient sensitivity
for detecting changes in stroke volume.
Meaning: SVV and PVV are innacurate in situtations of spontaneous breathing, ventilation
to a tidal volume of less than 8-10 mL/kg, and in patients with cardiac arrhythmias. In
contrast, measuring SV in context of a PLR retains accuracy in these situations.
Bioreactance has been shown to be highly accurate in.
9.
Lamia B, Ochagavia A, Monnet X, et al. Echocardiographic prediction of volume
responsiveness in critically ill patients with spontaneously breathing activity. Care Med
2007; 33:11251132
A passive leg raising induced increase in stroke volume of 12.5% or more predicted an
increase in stroke volume of 15% or more after volume expansion with a sensitivity of 77%
and a specicity of 100%. Neither left ventricular end-diastolic area nor the ratio of mitral
inow wave velocity to early diastolic mitral annulus velocity predicted volume responsiveness.
In our critically ill patients with spontaneous breathing activity the response of echocardiographic
stroke volume to passive leg raising was a good predictor of volume responsiveness. On the
other hand, the common echocardiographic markers of cardiac lling status were not valuable
for this purpose.
Meaning: As in Maizel, et al.
5.