PASSIVE LEG RAISING: An indicator of fluid responsiveness in sepsis

Dr. Soumar Dutta MD (PG), Dr. V.P Chandrasekharan, M.D (A&E), Dip (A&E), HODDepartment of Emergency and Critical Care Medicine

Vinayaka Missions Hospital, Salem

• The clinical determination of the intravascular volume can be extremely difficult in critically ill patients, specially those in sepsis.

• Early aggressive resuscitation of critically ill sepsis patients may limit and/or reverse tissue hypoxia, progression to organ failure, and improve outcome.

Introduction

End point resuscitation

• Central venous pressure 8-12 mm Hg• Mean arterial pressure (MAP) ≥ 65 mm Hg• Urine output ≥ 0.5 ml/kg/hr.• Central venous (Superior vena cava) or mixed venous

oxygen saturation 70 % or 65% respectively

End point resuscitation

Aim

To assess whether passive leg raising can help in predicting fluid responsiveness in patients with sepsis and acute circulatory failure.

Methodology

• Study design: Prospective, analytical study conducted in the

emergency room and intensive care units of a multispecialty teaching University in Salem.

• Study period:July 2012 to August 2013

Methodology

• Study group: The study population were subjected to following limitations:

Inclusion criterias:All cases of sepsis • Age > 18 years• Circulatory failure

Exclusion criterias:• Arrhythmias• Pelvic/lower limb fracture• Parturient• Amputation of the lower limbs• Clinical or radiological evidence of mediastinal mass • Pneumothorax/hydrothorax

Methodology

• Data collection: Study measurements were taken in four stages. 30

ml/kgHemodynamic indices:

• Stroke volume (SV) using 2D echocardiography

MethodologyStroke volume assessment using 2D ECHO

Stroke volume = LVOT area x Quantity of blood across LVOT

Parasternal long axis view

LVOTDiameter

LVOT = Left Ventricular Outflow TractVTI = Velocity Time Integral

π x (diameter)2

Stroke Volume = ------------------------------ x LVOT VTI 4

MethodologyStroke volume assessment using 2D ECHO

π x (diameter)2

Stroke Volume : ------------------------- x LVOT VTI 4

Apical 5 chamber view

Methodology

Septic shock

Fluid bolus by treating physician

Stroke volume assessment with and without PLR

Treating physician who give bolus is blinded to ECHO findings

Haemodynamic changes in passive leg raising

Blood shifts toward the intrathoracic compartment

45°

Methodology

Frank-starling principle

Stroke volume

Ventricular preload

normal heart

failing heart

Preload-dependence

Preload-independence

Terminologies

Those who had ≥15% increase

in SV is considered as

predicted response

Those who had <15% increase

in SV is considered as predicted no

response

Those who had any increase in blood pressure considered as

responsive

Those who had no increase in blood pressure considered as

non responsive

Results

A total of 116 patients were evaluated out of whom 73 were fluid responders.

Responders

Non-responders

43 (37%)

73 (63%)

n = 116

Results

Responded to fluid challenge

TotalYes No

Predicted

Response

Yes 64 0 64

No 9 43 52

Total 73 43 116

Series1

0

10

20

30

40

50

60

70

BEFORE

Stroke Volume(∆SV) among fluid responders before and after PLR

Results

n=73

Before Volume Expansion

Series1

0

10

20

30

40

50

60

70

80

Before After

After volume expansion

Results

VE (30ml/kg) :Stroke volume before and after PLR

Results

Sensitivity SpecificityPositive

predictive value

Negative predictive

value

87.67 % 100% 100% 82.69%

Conclusion

• A simple, non-invasive bedside test for volume responsiveness which challenges patient’s own “Frank-Starling curve”• Brief and completely reversible “self volume challenge” . • Reduces the use of vasopressors and overzealous fluid

administration.• Can be repeated over in the same patient.

Thank you