Passive leg raise

Last updated
Passive leg raise
The five key points for a reliable passive leg raising test.gif
passive leg raising test
Synonyms Shock position

Passive leg raise, also known as shock position, is a treatment for shock or a test to evaluate the need for further fluid resuscitation in a critically ill person. [1]

It is the position of a person who is lying flat on their back with the legs elevated approximately 8–12 inches (200–300 mm). [2] [3] [4] [5] The purpose of the position is to elevate the legs above the heart in a manner that will help blood flow to the heart.

This test involves raising the legs of a person's (without their active participation), which causes gravity to pull blood from the legs, thus increasing circulatory volume available to the heart (cardiac preload) by around 150-300 milliliters, depending on the amount of venous reservoir. [1] The real-time effects of this maneuver on hemodynamic parameters such as blood pressure and heart rate are used to guide the decision whether or not more fluid will be beneficial. [6] [7] The assessment is easier when invasive monitoring is present (such as an arterial catheter).

The maneuver might be reinforced in a clinical setting by moving the patient's bed from a semi-recumbent (half sitting, half laying down) position to a recumbent (laying down) position with the legs raised. This is theorised to cause an additional mobilisation of blood from the gastrointestinal circulation. [8] [9] Direct measurement of cardiac output is the more reliable comparing to the measurement of blood pressure or pulse pressure because of pulse pressure amplification 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 elevated manually because it may provoke pain, discomfort, or awakening that can cause adrenergic stimulation, giving false readings of cardiac output by increasing heart rate. After the maneuver, the bed should be placed back into semi-recumbent position with cardiac output 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, where the latter can lead to fluid overload. [10] Compression stockings should be removed before the test so that adequate volume of blood will return to the heart during the maneuver. [11] 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. [12]

Several studies showed 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. [12]

Placing the person in the Trendelenburg position, does not work since bloodvessels are highly compliant, and expand as result of the increased volume locally. More suitable would be the use of vasopressors. [2] [3] [4] [5]

Related Research Articles

<span class="mw-page-title-main">Blood pressure</span> Pressure exerted by circulating blood upon the walls of arteries

Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" refers to the pressure in a brachial artery, where it is most commonly measured. Blood pressure is usually expressed in terms of the systolic pressure over diastolic pressure in the cardiac cycle. It is measured in millimeters of mercury (mmHg) above the surrounding atmospheric pressure, or in kilopascals (kPa).

<span class="mw-page-title-main">Shock (circulatory)</span> Medical condition of insufficient blood flow

Shock is the state of insufficient blood flow to the tissues of the body as a result of problems with the circulatory system. Initial symptoms of shock may include weakness, fast heart rate, fast breathing, sweating, anxiety, and increased thirst. This may be followed by confusion, unconsciousness, or cardiac arrest, as complications worsen.

<span class="mw-page-title-main">Sepsis</span> Life-threatening organ dysfunction triggered by infection

Sepsis, or blood poisoning, is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs.

<span class="mw-page-title-main">Cardiac output</span> Measurement of blood pumped by the heart

In cardiac physiology, cardiac output (CO), also known as heart output and often denoted by the symbols , , or , is the volumetric flow rate of the heart's pumping output: that is, the volume of blood being pumped by a single ventricle of the heart, per unit time. Cardiac output (CO) is the product of the heart rate (HR), i.e. the number of heartbeats per minute (bpm), and the stroke volume (SV), which is the volume of blood pumped from the left ventricle per beat; thus giving the formula:

<span class="mw-page-title-main">Fluid replacement</span>

Fluid replacement or fluid resuscitation is the medical practice of replenishing bodily fluid lost through sweating, bleeding, fluid shifts or other pathologic processes. Fluids can be replaced with oral rehydration therapy (drinking), intravenous therapy, rectally such as with a Murphy drip, or by hypodermoclysis, the direct injection of fluid into the subcutaneous tissue. Fluids administered by the oral and hypodermic routes are absorbed more slowly than those given intravenously.

<span class="mw-page-title-main">Valsalva maneuver</span> Technique for equalising pressure in the middle ears

The Valsalva maneuver is performed by a forceful attempt of exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut while expelling air out as if blowing up a balloon. Variations of the maneuver can be used either in medical examination as a test of cardiac function and autonomic nervous control of the heart, or to clear the ears and sinuses when ambient pressure changes, as in scuba diving, hyperbaric oxygen therapy, or air travel.

<span class="mw-page-title-main">Pulmonary edema</span> Fluid accumulation in the tissue and air spaces of the lungs

Pulmonary edema, also known as pulmonary congestion, is excessive liquid accumulation in the tissue and air spaces of the lungs. It leads to impaired gas exchange and may cause hypoxemia and respiratory failure. It is due to either failure of the left ventricle of the heart to remove oxygenated blood adequately from the pulmonary circulation, or an injury to the lung tissue directly or blood vessels of the lung.

<span class="mw-page-title-main">Acute respiratory distress syndrome</span> Human disease

Acute respiratory distress syndrome (ARDS) is a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. Symptoms include shortness of breath (dyspnea), rapid breathing (tachypnea), and bluish skin coloration (cyanosis). For those who survive, a decreased quality of life is common.

<span class="mw-page-title-main">Hypotension</span> Abnormally low blood pressure

Hypotension is low blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood. Blood pressure is indicated by two numbers, the systolic blood pressure and the diastolic blood pressure, which are the maximum and minimum blood pressures, respectively. A systolic blood pressure of less than 90 millimeters of mercury (mmHg) or diastolic of less than 60 mmHg is generally considered to be hypotension. Different numbers apply to children. However, in practice, blood pressure is considered too low only if noticeable symptoms are present.

<span class="mw-page-title-main">Pulse oximetry</span> Measurement of blood oxygen saturation

Pulse oximetry is a noninvasive method for monitoring a person's blood oxygen saturation. Peripheral oxygen saturation (SpO2) readings are typically within 2% accuracy of the more accurate reading of arterial oxygen saturation (SaO2) from arterial blood gas analysis. But the two are correlated well enough that the safe, convenient, noninvasive, inexpensive pulse oximetry method is valuable for measuring oxygen saturation in clinical use.

<span class="mw-page-title-main">Mean arterial pressure</span> Average blood pressure in an individual during a single cardiac cycle

In medicine, the mean arterial pressure (MAP) is an average calculated blood pressure in an individual during a single cardiac cycle. Although methods of estimating MAP vary, a common calculation is to take one-third of the pulse pressure, and add that amount to the diastolic pressure. A normal MAP is about 90 mmHg.

<span class="mw-page-title-main">Hypovolemic shock</span> Medical condition

Hypovolemic shock is a form of shock caused by severe hypovolemia. It could be the result of severe dehydration through a variety of mechanisms or blood loss. Hypovolemic shock is a medical emergency; if left untreated, the insufficient blood flow can cause damage to organs, leading to multiple organ failure.

<span class="mw-page-title-main">Cardiogenic shock</span> Medical emergency resulting from inadequate blood flow due to dysfunction of heart ventricles

Cardiogenic shock (CS) is a medical emergency resulting from inadequate blood flow due to the dysfunction of the ventricles of the heart. Signs of inadequate blood flow include low urine production, cool arms and legs, and altered level of consciousness. People may also have a severely low blood pressure and heart rate.

<span class="mw-page-title-main">Pulmonary artery catheter</span> Catheter for insertion into a pulmonary artery

A pulmonary artery catheter (PAC), also known as a Swan-Ganz catheter or right heart catheter, is a balloon-tipped catheter that is inserted into a pulmonary artery in a procedure known as pulmonary artery catheterization or right heart catheterization. Pulmonary artery catheterization is a useful measure of the overall function of the heart particularly in those with complications from heart failure, heart attack, arrythmias or pulmonary embolism. It is also a good measure for those needing intravenous fluid therapy, for instance post heart surgery, shock, and severe burns. The procedure can also be used to measure pressures in the heart chambers.

Pulsus paradoxus, also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. Pulsus paradoxus is not related to pulse rate or heart rate, and it is not a paradoxical rise in systolic pressure. Normally blood pressure should increase during inhalation. Pulsus paradoxus is a sign that is indicative of several conditions most commonly pericardial effusion.

Central venous pressure (CVP) is the blood pressure in the venae cavae, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood back into the arterial system. CVP is often a good approximation of right atrial pressure (RAP), although the two terms are not identical, as a pressure differential can sometimes exist between the venae cavae and the right atrium. CVP and RAP can differ when arterial tone is altered. This can be graphically depicted as changes in the slope of the venous return plotted against right atrial pressure.

Early goal-directed therapy was introduced by Emanuel P. Rivers in The New England Journal of Medicine in 2001 and is a technique used in critical care medicine involving intensive monitoring and aggressive management of perioperative hemodynamics in patients with a high risk of morbidity and mortality. In cardiac surgery, goal-directed therapy has proved effective when commenced after surgery. The combination of GDT and Point-of-Care Testing has demonstrated a marked decrease in mortality for patients undergoing congenital heart surgery. Furthermore, a reduction in morbidity and mortality has been associated with GDT techniques when used in conjunction with an electronic medical record.

<span class="mw-page-title-main">Neurointensive care</span> Branch of medicine that deals with life-threatening diseases of the nervous system

Neurocritical care is a medical field that treats life-threatening diseases of the nervous system and identifies, prevents, and treats secondary brain injury.

Obstructive shock is one of the four types of shock, caused by a physical obstruction in the flow of blood. Obstruction can occur at the level of the great vessels or the heart itself. Causes include pulmonary embolism, cardiac tamponade, and tension pneumothorax. These are all life-threatening. Symptoms may include shortness of breath, weakness, or altered mental status. Low blood pressure and tachycardia are often seen in shock. Other symptoms depend on the underlying cause.

quantium Medical Cardiac Output (qCO) uses impedance cardiography in a simple, continuous, and non-invasive way to estimate the cardiac output (CO) and other hemodynamic parameters such as the stroke volume (SV) and cardiac index (CI). The CO estimated by the qCO monitor is referred to as the "qCO". The impedance plethysmography allows determining changes in volume of the body tissues based on the measurement of the electric impedance at the body surface.

References

  1. 1 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.
  2. 1 2 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.
  3. 1 2 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.
  4. 1 2 "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.
  5. 1 2 Harrison's Principles of Internal Medicine. Archived from the original on 2012-08-04.
  6. Boulain T, Achard JM, Teboul JL, Richard C, Perrotin D, Ginies G (April 2002). "Changes in BP induced by passive leg raising predict response to fluid loading in critically ill patients". Chest. 121 (4): 1245–52. doi:10.1378/chest.121.4.1245. PMID   11948060.
  7. 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.
  8. 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.
  9. 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.
  10. Xavier, Monnet (14 January 2015). "Passive leg raising: five rules, not a drop of fluid!". Critical Care. 19 (18): 237. doi:10.1186/s13054-014-0708-5. PMC   4293822 . PMID   25658678.
  11. 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.
  12. 1 2 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.

See also