The passive leg raising test to guide fluid removal in critically ill patients

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Abstract

Background

To investigate whether haemodynamic intolerance to fluid removal during intermittent renal replacement therapy (RRT) in critically ill patients can be predicted by a passive leg raising (PLR) test performed before RRT.

Methods

We included 39 patients where intermittent RRT with weight loss was decided. Intradialytic hypotension was defined as hypotension requiring a therapeutic intervention, as decided by the physicians in charge. Before RRT, the maximal increase in cardiac index (CI, pulse contour analysis) induced by a PLR test was recorded. RRT was then started.

Results

Ultrafiltration rate was similar in patients with and without intradialytic hypotension. Thirteen patients presented intradialytic hypotension, while 26 did not. In patients with intradialytic hypotension, it occurred 120 min [interquartile range 60–180 min] after onset of RRT. In the 26 patients without intradialytic hypotension, the PLR test induced no significant change in CI. Conversely, in patients with intradialytic hypotension, PLR significantly increased CI by 15 % [interquartile range 11–36 %]. The PLR-induced increase in CI predicted intradialytic hypotension with an area under the ROC curve of 0.89 (95 % interval confidence 0.75–0.97) ( p < 0.05 from 0.50). The best diagnostic threshold was 9 %. The sensitivity was 77 % (95 % confidence interval 46–95 %), the specificity was 96 % (80–100 %), the positive predictive value was 91 % (57–100 %), and the negative predictive value was 89 % (72–98 %). Compared to patients without intolerance to RRT, CI decreased significantly faster in patients with intradialytic hypotension, with a slope difference of −0.17 L/min/m ²/h.

Conclusion

The presence of preload dependence, as assessed by a positive PLR test before starting RRT with fluid removal, predicts that RRT will induce haemodynamic intolerance.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-016-0149-1) contains supplementary material, which is available to authorized users.

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Most cited references 28

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A positive fluid balance is associated with a worse outcome in patients with acute renal failure

Didier Payen, Anne-Cornélie JM de Pont, Yasser Sakr … (2008)

Introduction Despite significant improvements in intensive care medicine, the prognosis of acute renal failure (ARF) remains poor, with mortality ranging from 40% to 65%. The aim of the present observational study was to analyze the influence of patient characteristics and fluid balance on the outcome of ARF in intensive care unit (ICU) patients. Methods The data were extracted from the Sepsis Occurrence in Acutely Ill Patients (SOAP) study, a multicenter observational cohort study to which 198 ICUs from 24 European countries contributed. All adult patients admitted to a participating ICU between 1 and 15 May 2002, except those admitted for uncomplicated postoperative surveillance, were eligible for the study. For the purposes of this substudy, patients were divided into two groups according to whether they had ARF. The groups were compared with respect to patient characteristics, fluid balance, and outcome. Results Of the 3,147 patients included in the SOAP study, 1,120 (36%) had ARF at some point during their ICU stay. Sixty-day mortality rates were 36% in patients with ARF and 16% in patients without ARF (P < 0.01). Oliguric patients and patients treated with renal replacement therapy (RRT) had higher 60-day mortality rates than patients without oliguria or the need for RRT (41% versus 33% and 52% versus 32%, respectively; P < 0.01). Independent risk factors for 60-day mortality in the patients with ARF were age, Simplified Acute Physiology Score II (SAPS II), heart failure, liver cirrhosis, medical admission, mean fluid balance, and need for mechanical ventilation. Among patients treated with RRT, length of stay and mortality were lower when RRT was started early in the course of the ICU stay. Conclusion In this large European multicenter study, a positive fluid balance was an important factor associated with increased 60-day mortality. Outcome among patients treated with RRT was better when RRT was started early in the course of the ICU stay.

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Hemodynamic parameters to guide fluid therapy

Paul E Marik, Xavier Monnet, Jean-Louis Teboul (2011)

The clinical determination of the intravascular volume can be extremely difficult in critically ill and injured patients as well as those undergoing major surgery. This is problematic because fluid loading is considered the first step in the resuscitation of hemodynamically unstable patients. Yet, multiple studies have demonstrated that only approximately 50% of hemodynamically unstable patients in the intensive care unit and operating room respond to a fluid challenge. Whereas under-resuscitation results in inadequate organ perfusion, accumulating data suggest that over-resuscitation increases the morbidity and mortality of critically ill patients. Cardiac filling pressures, including the central venous pressure and pulmonary artery occlusion pressure, have been traditionally used to guide fluid management. However, studies performed during the past 30 years have demonstrated that cardiac filling pressures are unable to predict fluid responsiveness. During the past decade, a number of dynamic tests of volume responsiveness have been reported. These tests dynamically monitor the change in stroke volume after a maneuver that increases or decreases venous return (preload) and challenges the patients' Frank-Starling curve. These dynamic tests use the change in stroke volume during mechanical ventilation or after a passive leg raising maneuver to assess fluid responsiveness. The stroke volume is measured continuously and in real-time by minimally invasive or noninvasive technologies, including Doppler methods, pulse contour analysis, and bioreactance.

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Passive leg raising predicts fluid responsiveness in the critically ill.

Xavier Monnet, Mario Rienzo, David Osman … (2006)

Passive leg raising (PLR) represents a "self-volume challenge" that could predict fluid response and might be useful when the respiratory variation of stroke volume cannot be used for that purpose. We hypothesized that the hemodynamic response to PLR predicts fluid responsiveness in mechanically ventilated patients. Prospective study. Medical intensive care unit of a university hospital. We investigated 71 mechanically ventilated patients considered for volume expansion. Thirty-one patients had spontaneous breathing activity and/or arrhythmias. We assessed hemodynamic status at baseline, after PLR, and after volume expansion (500 mL NaCl 0.9% infusion over 10 mins). We recorded aortic blood flow using esophageal Doppler and arterial pulse pressure. We calculated the respiratory variation of pulse pressure in patients without arrhythmias. In 37 patients (responders), aortic blood flow increased by > or =15% after fluid infusion. A PLR increase of aortic blood flow > or =10% predicted fluid responsiveness with a sensitivity of 97% and a specificity of 94%. A PLR increase of pulse pressure > or =12% predicted volume responsiveness with significantly lower sensitivity (60%) and specificity (85%). In 30 patients without arrhythmias or spontaneous breathing, a respiratory variation in pulse pressure > or =12% was of similar predictive value as was PLR increases in aortic blood flow (sensitivity of 88% and specificity of 93%). In patients with spontaneous breathing activity, the specificity of respiratory variations in pulse pressure was poor (46%). The changes in aortic blood flow induced by PLR predict preload responsiveness in ventilated patients, whereas with arrhythmias and spontaneous breathing activity, respiratory variations of arterial pulse pressure poorly predict preload responsiveness.

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Author and article information

Contributors

Xavier Monnet: + 33 1 45 21 35 39 , xavier.monnet@aphp.fr

Flora Cipriani: flora.cipriani@yahoo.com

Laurent Camous: laurent_lau@hotmail.com

Pierre Sentenac: pierre.sentenac@orange.fr

Martin Dres: martin.dres@aphp.fr

Evguenia Krastinova: krastinova@gmail.com

Nadia Anguel: adia.anguel@aphp.fr

Christian Richard: christian.richard@aphp.fr

Jean-Louis Teboul: jean-louis.teboul@aphp.fr

Journal

Journal ID (nlm-ta): Ann Intensive Care

Journal ID (iso-abbrev): Ann Intensive Care

Title: Annals of Intensive Care

Publisher: Springer Paris (Paris )

ISSN (Electronic): 2110-5820

Publication date (Electronic): 20 May 2016

Publication date PMC-release: 20 May 2016

Publication date Collection: 2016

Volume: 6

Electronic Location Identifier: 46

Affiliations

[ ]Service de réanimation médicale, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, 78, rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France

[ ]Faculté de médecine Paris-Sud, Inserm UMR S_999, Univ Paris-Sud, 63, rue Gabriel Péri, 94270 Le Kremlin-Bicêtre, France

[ ]Service de santé publique, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, 78, rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France

[ ]Service de réanimation médicale, Centre Hospitalier Universitaire de Bicêtre, 78, rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France

Article

Publisher ID: 149

DOI: 10.1186/s13613-016-0149-1

PMC ID: 4875574

PubMed ID: 27207178

SO-VID: 2a760a11-ab28-47d0-b4e6-06108d197616

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 2 March 2016

Date accepted : 28 April 2016

Custom metadata

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: passive leg raising,renal replacement therapy,ultrafiltration,volume responsiveness,acute kidney injury,hypotension

Data availability:

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: passive leg raising, renal replacement therapy, ultrafiltration, volume responsiveness, acute kidney injury, hypotension

The passive leg raising test to guide fluid removal in critically ill patients

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Most cited references 28

A positive fluid balance is associated with a worse outcome in patients with acute renal failure

Hemodynamic parameters to guide fluid therapy

Passive leg raising predicts fluid responsiveness in the critically ill.

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