Passive leg raise

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Passive leg raise
The five key points for a reliable passive leg raising test
passive leg raising test
SynonymsShock position

Passive leg raise, also known as shock position, is a treatment for shock or a test to predict the response to rapid fluid loading[1] during fluid resuscitation.[2]

The position consists of a person lying flat on their back with their legs elevated 8–12 inches (200–300 mm).[3][4][5][6] This is done to keep the legs above the heart, helping blood flow to the heart via gravity. This increases the volume of blood available to the heart (cardiac preload) by 150-300 milliliters.[2] The real-time effects of this on parameters such as blood pressure and heart rate assist medical professionals.[7][8]

In a clinical setting, a patient's bed may be moved from a semi-recumbent position (half sitting, half laying down) to a recumbent position (lying down) position with the legs raised. This is theorized to cause additional mobilisation of blood from the gastrointestinal circulation.[9][10]

The assessment is easier with invasive monitoring (such as an arterial catheter). The monitoring provides real-time measurements of cardiac output, which helps keep track of blood pressure or pulse while they amplify during this procedure. Cardiac output can be measured by arterial pulse contour analysis, echocardiography, esophageal Doppler, or contour analysis of the volume clamp-derived arterial pressure. Any bronchial secretions must be aspirated before performing this test.

The legs should not be manually elevated because this may provoke pain, discomfort, or awakening, leading to adrenergic stimulation and false cardiac output readings by increasing heart rate. After the maneuver, the bed should be placed back into semi-recumbent position, and cardiac output should be measured again. The cardiac output should return to the values measured before the initiation of this maneuver. This test can be used to assess fluid responsiveness without any fluid challenge, which can lead to fluid overload.[11] Compression stockings should be removed before the test so that adequate volume of blood will return to the heart during the maneuver.[12] The physiology of assessing fluid responsiveness via passive leg raise requires increasing systemic venous return without altering cardiac function—a form of functional hemodynamic monitoring.[13]

Several studies have shown that this measure is a better predictor of response to rapid fluid loading than other tests, such as respiratory variation in pulse pressure or echocardiographic markers.[13]

Placing the person in the Trendelenburg position does not work as blood vessels are highly compliant and expand as a result of the increased volume locally. A more suitable option would be the use of vasopressors.[3][4][5][6]

See also

References

  1. Gillis, Holly C; Walia, Hina; Tumin, Dmitry; Bhalla, Tarun; Tobias, Joseph D (17 September 2018). "Rapid fluid administration: an evaluation of two techniques". Medical Devices: Evidence and Research. 11. Dove Medical Press Limited: 331–336. doi:10.2147/MDER.S172340. PMC 6147200. PMID 30271225.
  2. Monnet X, Teboul JL (April 2008). "Passive leg raising". Intensive Care Med. 34 (4): 659–63. doi:10.1007/s00134-008-0994-y. PMID 18214429.
  3. Irwin, Richard S.; Rippe, James M. (January 2003). Intensive Care Medicine. Lippincott Williams & Wilkins, Philadelphia & London. ISBN 978-0-7817-3548-3. Archived from the original on 2005-11-07.
  4. Marino, Paul L. (September 2006). The ICU Book. Lippincott Williams & Wilkins, Philadelphia & London. ISBN 978-0-7817-4802-5. Archived from the original on 2009-11-29. Retrieved 2018-10-24.
  5. "Fundamental Critical Care Support, A standardized curriculum of Critical Care". Society of Critical Care Medicine, Des Plaines, Illinois. Archived from the original on 2007-09-28. Retrieved 2018-10-24.
  6. Harrison's Principles of Internal Medicine. Archived from the original on 2012-08-04.
  7. Boulain, Thierry; Achard, Jean-Michel; Teboul, Jean-Louis; Richard, Christian; Perrotin, Dominique; Ginies, Guy (April 2002). "Changes in BP Induced by Passive Leg Raising Predict Response to Fluid Loading in Critically Ill Patients". Chest. 121 (4). The American College of Chest Physicians: 1245–1252. doi:10.1378/chest.121.4.1245. PMID 11948060.
  8. Maizel J, Airapetian N, Lorne E, Tribouilloy C, Massy Z, Slama M (July 2007). "Diagnosis of central hypovolemia by using passive leg raising". Intensive Care Med. 33 (7): 1133–8. doi:10.1007/s00134-007-0642-y. PMID 17508202.
  9. Jabot J, Teboul JL, Richard C, Monnet X (September 2008). "Passive leg raising for predicting fluid responsiveness: importance of the postural change". Intensive Care Med. 35 (1): 85–90. doi:10.1007/s00134-008-1293-3. PMID 18795254.
  10. Teboul JL, Monnet X (June 2008). "Prediction of volume responsiveness in critically ill patients with spontaneous breathing activity". Curr Opin Crit Care. 14 (3): 334–9. doi:10.1097/MCC.0b013e3282fd6e1e. PMID 18467896.
  11. Xavier, Monnet (14 January 2015). "Passive leg raising: five rules, not a drop of fluid!". Critical Care. 19 (18) 18: 237. doi:10.1186/s13054-014-0708-5. PMC 4293822. PMID 25658678.
  12. Jacob Chakco, Cyril; P Wise, Matt; J Frost, Paul (1 June 2015). "Passive leg raising and compression stockings: a note of caution". Critical Care. 19 (237): 237. doi:10.1186/s13054-015-0955-0. PMC 4450449. PMID 26028257.
  13. Monnet, X; Marik, PE; Teboul, JL (December 2016). "Prediction of fluid responsiveness: an update". Annals of Intensive Care. 6 (1): 111. doi:10.1186/s13613-016-0216-7. PMC 5114218. PMID 27858374.