{"id":5323,"date":"2011-07-14T20:25:28","date_gmt":"2011-07-14T20:25:28","guid":{"rendered":"http:\/\/crashtext.org\/misc\/predicting-fluid-responsiveness.htm\/"},"modified":"2015-09-06T21:26:03","modified_gmt":"2015-09-07T01:26:03","slug":"predicting-fluid-responsiveness","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/resuscitation\/predicting-fluid-responsiveness.htm\/","title":{"rendered":"Predicting Fluid Responsiveness"},"content":{"rendered":"

Great review from Chest<\/a><\/p>\n

And Another from Paul Marik<\/a> and another from Paul Marik<\/a><\/p>\n

and another from JL Vincent Consensus of 16 from Crit Care 2011<\/p>\n

Passive Leg raising and End-exp occlusion was good in pts with poor resp compliance; PPV was not (Crit Care Med 2012;40(1):151)<\/p>\n

A new article seems to indicate that the best predictor for development of pulmonary edema during fluid loading is reaching plateau of CI, indicated by no additional increase with fluids (CCM 2012; 40:793)<\/p>\n

<\/span>Marik Phillips Curves<\/span><\/h2>\n

\"marik-phillips<\/a><\/p>\n

<\/span>The Fluid Challenge<\/span><\/h2>\n

Fluid Challenge Revisited<\/a> (CCM 2006;34:1333)<\/p>\n

2-5 rule<\/p>\n

Check in at 10 minutes, if CVP increase <2, continue<\/p>\n

2-5 Stop infusion, and wait 10 minutes. If it drops back to less than 2, continue<\/p>\n

>5 Stop fluid challenge<\/p>\n

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CVP<\/p>\n

kinda sucks<\/p>\n

Many articles<\/p>\n

this one is nice (<\/p>\n

Crit Care Med 2007 Vol. 35, No. 1:64<\/a><\/p>\n

<\/span>ETCO2<\/span><\/h2>\n

A PLR-induced increase in EtCO2 >5 % predicted a fluid induced increase in CI >15 % with sensitivity of 71 % (95 % confidence interval: 48\u201389 %) and specificity of 100 (82\u2013100) %. (Intensive Care Med (2013) 39:93\u2013100)<\/p>\n

Passive leg raise to etco2 New balanced retro study Ccm 2014;42:1585<\/p>\n

<\/span>NICOM – Bioreactance<\/span><\/h2>\n

Marik studied 34 patients in the ICU with PLR, NICOM, SVV, and Carotid Flow (The use of NICOM (Bioreactance) and Carotid Doppler to determine volume responsiveness and blood flow redistribution following passive leg raising in hemodynamically unstable patients Chest 2012 Marik et al.)<\/p>\n

Big validation study showed good accuracy (Intensive Care Med (2007) 33:1191\u20131194)<\/p>\n

New study in only 11 pts shows poor correlation with PAC (Fagnoul et al. Critical Care 2012, 16:460)<\/p>\n

A 2nd study showing poor correlation in the critically ill (Br J Anaesth 2013;111(6):961)<\/p>\n

<\/span>Passive Leg Raise<\/span><\/h2>\n

Passive leg-raising PLR to 30\u00b0 transiently increases venous return [64] in patients who are preload responsive. As PLR only transiently increases CO and blood pressure [65] in responders, it is only a diagnostic test and cannot be considered as a treatment for hypovolemia. The main advantage of the PLR approach is that it is reversible and easy to perform in patients breathing spontaneously and with arrhythmias [66\u0095\u0095]. It also can be repeated many times to reassess preload responsiveness without any risk of inducing pulmonary edema or cor pulmonale in potential nonresponders. One of the major limitations of this technique is that in severely hypovolemic patients, the blood volume mobilized by leg-raising which is dependent on total blood volume could be small, which, in turn, can show minimal to no increase in CO and blood pressure, even in responders.<\/p>\n

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The passive leg-raising test Lifting the legs passively from the horizontal position induces a gravitational transfer of blood from the lower limbs toward the intrathoracic compartment (Fig. 2). Several studies conducted in various hemodynamic conditions have demonstrated an increase in the pulmonary artery occlusion pressure [38], in the left ventricular end-diastolic dimension [9], or in the left ventricular ejection time [18\u0095\u0095] during passive leg raising (PLR), supporting the evidence that the volume of blood transferred to the heart during PLR is sufficient to increase the left cardiac preload and thus to challenge the Frank-Starling curve. Beyond its ease of use, the method has the advantage of inducing reversible effects once the legs are tilted down [18\u0095\u0095,38]. Therefore, PLR may act as a \u0091reversible self-volume challenge\u0092.<\/p>\n

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The concept of fluid response prediction by using PLR has emerged from the study by Boulain and coworkers [38], in which the increase in thermodilution stroke volume following a fluid infusion correlated with the increase in arterial pulse pressure produced by PLR. Recently, we demonstrated the full ability of PLR to serve as a test for preload responsiveness [18\u0095\u0095]. In 71 patients with acute circulatory failure, changes in aortic blood flow (measured by esophageal Doppler) during a 45\u00b0 leg elevation enabled us to predict the changes in aortic blood flow produced by a 500 ml fluid challenge. This was the case even in the subgroup of patients with cardiac arrhythmias or spontaneous ventilator triggering, situations in which respiratory variation of arterial pulse pressure lost any predictive ability. Probably descending aortic blood flow was a better measure of cardiac output than pulse pressure, volume responsiveness was better predicted by PLR-induced changes in aortic blood flow than by PLR-induced changes in arterial pulse pressure. In another series of patients fully adapted to their ventilator, Lafanechere et al. [17\u0095] also found that fluid responsiveness could be reliably predicted by the response of descending aortic blood flow to PLR. Since the maximal hemodynamic effects of PLR occurred within the first minute of leg elevation [18\u0095\u0095], it is important to assess these effects with a method able to track changes in cardiac output or stroke volume on a real-time basis. In this regard, the response of descending aortic blood flow (measured by esophageal Doppler) to PLR [17\u0095,18\u0095\u0095] as well as the response of the velocity\u0096time integral (measured by transthoracic echocardiography) [39] to PLR have been demonstrated to be helpful in predicting the response to volume administration in patients with spontaneous<\/p>\n

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17\u0095 Lafanechere A, Pene F, Goulenok C, et al. Changes in aortic blood flow induced by passive leg raising predict fluid responsiveness in critically ill patients. Crit Care 2006; 10:R132. Mount Sinai Serials This study confirms the reliability of the PLR test for predicting volume responsiveness by means of esophageal Doppler monitoring, as demonstrated by Monnet et al. [18\u0095\u0095]. [Context Link] 18\u0095\u0095 Monnet X, Rienzo M, Osman D, et al. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med 2006; 34:1402\u00961407. Ovid Full Text Mount Sinai Serials In 71 patients with acute circulatory failure, increases in the aortic blood flow measured by esophageal Doppler by more than 10% allows one to predict volume responsiveness with a sensitivity of 97% and a specificity of 94%. Importantly, in a subgroup of patients with spontaneous breathing activity or cardiac arrhythmias, PLR kept its full predictive value while the respiratory variation of pulse pressure was ineffective for predicting volume responsiveness. [Context Link]<\/p>\n

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38 Boulain T, Achard JM, Teboul JL, et al. Changes in BP induced by passive leg raising predict response to fluid loading in critically ill patients. Chest 2002; 121:1245\u00961252. Mount Sinai Serials Bibliographic Links [Context Link]<\/p>\n

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Passive leg raising-induced changes in mean radial artery pressure can be used to assess preload dependence if it goes up<\/p>\n

Critical Care 2007, 11(Suppl 2):P307<\/p>\n

(Chest. 2002;121:1245-1252.) Changes in BP Induced by Passive Leg Raising Predict Response to Fluid Loading in Critically Ill Patients*<\/p>\n

Most recent analysis states changes in MAP don’t predict CI increase from fluid load in septic shock (Intensive Care Med (2012) 38:422\u2013428)<\/p>\n

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Thierry Boulain, MD; Jean-Michel Achard, MD; Jean-Louis Teboul, MD; Christian Richard, MD; Dominique Perrotin, MD and Guy Ginies, MD<\/p>\n

Author(s):<\/p>\n

Monnet, Xavier MD, PhD; Rienzo, Mario MD; Osman, David MD; Anguel, Nadia MD; Richard, Christian MD; Pinsky, Michael R. MD, Dr hc; Teboul, Jean-Louis MD, PhD<\/p>\n

Issue:Volume 34(5),\u00a0May 2006,\u00a0pp 1402-1407<\/p>\n

Passive leg raising predicts fluid responsiveness in the critically ill *<\/p>\n

critical care medicine<\/p>\n

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>9% change in pulse pressure<\/strong> or > 10% in SV, by PLR predicted volume responsiveness in non-intubated spont breathing patients.<\/strong> (CCM 2010,38:819)<\/p>\n

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To know if your passive leg raise is accurate, you need to see the CVP increase by at least 2 mm Hg. If this occurs pulse pressure changes are accurate (8%)<\/p>\n

(Inten Care Med 2010;36:940)<\/p>\n

If there is not an increase, then you need a stroke volume marker and can’t use PP<\/p>\n

LR +9, LR-0.14<\/p>\n

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SR and MA (Inten Care Med 2010;36:1475)<\/p>\n

changes in CO are good markers, changes in ABP not as good<\/p>\n

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Not accurate in IAH patients (CCM\u00a0 2010;38:1824)<\/p>\n

Crit Care Med.<\/a> 2010 Mar;38(3):819-25.<\/p>\n

Passive leg raising is predictive of fluid responsiveness in spontaneously breathing patients with severe sepsis or acute pancreatitis.<\/p>\n

Pr\u00e9au S<\/a>, Saulnier F<\/a>, Dewavrin F<\/a>, Durocher A<\/a>, Chagnon JL<\/a>.<\/p>\n

Service de R\u00e9animation polyvalente, Centre Hospitalier Jean Bernard, Valenciennes, France. seb.preau@gmail.com<\/p>\n

Comment in:<\/p>\n