Passive leg raising an indicator of fluid responsiveness in sepsis
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Passive leg raising an indicator of fluid responsiveness in sepsis
- 1. 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), HOD Department of Emergency and Critical Care Medicine Vinayaka Missions Hospital, Salem
- 2. • 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
- 3. 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
- 5. Aim To assess whether passive leg raising can help in predicting fluid responsiveness in patients with sepsis and acute circulatory failure.
- 6. 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
- 7. 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
- 8. Methodology • Data collection: Study measurements were taken in four stages. 30ml /kg Hemodynamic indices: • Stroke volume (SV) using 2D echocardiography
- 9. Methodology Stroke volume assessment using 2D ECHO Stroke volume = LVOT area x Quantity of blood across LVOT Parasternal long axis view LVOT Diameter LVOT = Left Ventricular Outflow Tract VTI = Velocity Time Integral π x (diameter)2 Stroke Volume = ------------------------------ x LVOT VTI 4
- 10. Methodology Stroke volume assessment using 2D ECHO π x (diameter)2 Stroke Volume : ------------------------- x LVOT VTI 4 Apical 5 chamber view
- 11. 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
- 12. Haemodynamic changes in passive leg raising Blood shifts toward the intrathoracic compartment 45° Methodology
- 13. Frank-starling principle Stroke volume Ventricular preload normal heart failing heart Preload-dependence Preload-independence
- 14. 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
- 15. Results A total of 116 patients were evaluated out of whom 73 were fluid responders. Responders Non-responders 43 (37%) 73 (63%) n = 116
- 16. Results Responded to fluid challenge Total Yes No Predicted Response Yes 64 0 64 No 9 43 52 Total 73 43 116
- 17. 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
- 18. 0 10 20 30 40 50 60 70 80 Before After After volume expansion Results VE (30ml/kg) :Stroke volume before and after PLR
- 19. Results Sensitivity Specificity Positive predictive value Negative predictive value 87.67 % 100% 100% 82.69%
- 20. 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.
Notes de l'éditeur
- My topic is whether PLR can be used as an effective tool for predicting fluid responsiveness in sepsis
- INTRODUCTION: Fluid management is the cornerstone for initial treatment of critically ill sepsis patients who usually present in acute circulatory failure. Fluid volume replacement is often necessary to maintain adequate cardiac preload and output so that tissue perfusion is met. Predicting fluid responsiveness has become a topic of major Interest. Measurements of intravascular pressures and volumes often fail to predict the response to fluids, even though very low values are usually associated with a positive response to fluids. Whereas under-resuscitation results in inadequate organ perfusion, over-resuscitation is associated with complications of fluid overload and increased morbidity and mortality. The initial fluids resuscitation component of the sepsis bundle guidelines laid by SSC states that all sepsis patients should be resuscitated with an initial fluid bolus of 30ml/kg of crystalloids with a targeted end point of….
- Although measurement of CVP is currently the most readily obtainable target for fluid resuscitation and followed in most of the centres but it has got few disadvantages attributed to it. Apart from complications associated with insertion of a central line per se, it is invasive and time consuming and cannot be readily done in a busy setup.
- SSC also states that any intervention associated with the least physiological insult should be followed. Hence an alternative, rapid and non-invasive method of fluid assessment if available can replace conventional invasive method.
- Acute circulatory failure was defined as the presence of at least one clinical sign of inadequate tissue perfusion as follows: Systolic blood pressure <90 mmHg (or a decrease of >40 mmHg in previously hypertensive patients) The need for vasopressors to maintain a systolic blood pressure>90 mmHg Urine output of <0.5 ml/kg per hour for at least 1 hour Tachycardia Mottled skin.
- In stage one, the patient was placed in a semi-recumbent position with the head elevated at 45 degrees, and hemodynamic indices were collected as the baseline. In stage two, the patient was placed in a supine position with the legs straight and elevated at 45 degrees for two minutes before hemodynamic indices were taken. In stage three, the patient was returned to the baseline position. In stage four, hemodynamic indices were immediately collected after VE
- In the absence of significant valvular regurgitation, the left ventricle stroke volume can be calculated by measuring the left ventricle outflow tract (LVOT) area and the amount of blood going through this area In the parasternal long axis view zoom at the aortic root and measure at the level of aortic annulus after maximum systolic leaflet separation
- The amount of blood going through LVOT is given by VTI (velocity time integral) of the flow ; obtained by tracing the signal’s envelope. Pulsed wave (PW) doppler beam must be aligned with the LV outflow
- Two different emergency physicians conducted the study. The procedure was blinded as the first physician who gave fluid bolus was unaware of the ECHO outcome.
- When legs are passively raised from a semi-recumbent position; blood from lower limb and splanchnic vessels; amounting about 450ml shifts towards the thoracic compartment due to gravitational pull. The abrupt transfer of blood increases cardiac preload as a ‘self-volume challenge’ and, when both ventricles are operating in the steep part of the Frank-Starling curve, improves cardiac output.
- It states that within physiological range “When ventricles are stretched by increased diastolic fluid volume, systolic pressure generation increases”. So in a normal heart stroke volume increases with change in end- diastolic volume which fails to increase in a failing heart.
- Graphical representation among fluid responders before and after PLR prior to volume expansion.
- Graphical representation among fluid responders before and after PLR following to volume expansion shows significant increase in stroke volume
- Statistical analysis revealed that the study had a….
- So we concluded that PLR is a simple, noninvasive diagnostic tools allow clinicians to assess volume responsiveness using dynamic procedures that challenge the patients own Frank-Starling curve. Brief and completely reversible “self-volume challenge” , hence not associated with hazards of fluid overload Can be repeated over in the same patient to assess if the patient is further responsive to fluids.