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Fluid Challenge Revisited (CCM 2006;34:1333)
2-5 rule
Check in at 10 minutes, if CVP increase <2, continue
2-5 Stop infusion, and wait 10 minutes. If it drops back to less than 2, continue
>5 Stop fluid challenge
CVP
kinda sucks
Many articles
this one is nice (
Crit Care Med 2007 Vol. 35, No. 1:64
Passive leg-raising
PLR to 30° transiently increases venous return [64] in patients who are preload
responsive. As PLR only transiently increases CO and blood pressure [65] in
responders, it is only a diagnostic test and cannot be considered as a treatment
for hypovolemia. The main advantage of the PLR approach is that it is reversible
and easy to perform in patients breathing spontaneously and with arrhythmias
[66••]. It also can be repeated many times to reassess preload responsiveness
without any risk of inducing pulmonary edema or cor pulmonale in potential
nonresponders. One of the major limitations of this technique is that in
severely hypovolemic patients, the blood volume mobilized by leg-raising which
is dependent on total blood volume could be small, which, in turn, can show
minimal to no increase in CO and blood pressure, even in responders.
The passive leg-raising test
Lifting the legs passively from the horizontal position induces a gravitational
transfer of blood from the lower limbs toward the intrathoracic compartment
(Fig. 2). Several studies conducted in various hemodynamic conditions have
demonstrated an increase in the pulmonary artery occlusion pressure [38], in the
left ventricular end-diastolic dimension [9], or in the left ventricular
ejection time [18••] during passive leg raising (PLR), supporting the evidence
that the volume of blood transferred to the heart during PLR is sufficient to
increase the left cardiac preload and thus to challenge the Frank-Starling
curve. Beyond its ease of use, the method has the advantage of inducing
reversible effects once the legs are tilted down [18••,38]. Therefore, PLR may
act as a ‘reversible self-volume challenge’.
The concept of fluid response prediction by using PLR has emerged from the
study by Boulain and coworkers [38], in which the increase in thermodilution
stroke volume following a fluid infusion correlated with the increase in
arterial pulse pressure produced by PLR. Recently, we demonstrated the full
ability of PLR to serve as a test for preload responsiveness [18••]. In 71
patients with acute circulatory failure, changes in aortic blood flow (measured
by esophageal Doppler) during a 45° leg elevation enabled us to predict the
changes in aortic blood flow produced by a 500 ml fluid challenge. This was the
case even in the subgroup of patients with cardiac arrhythmias or spontaneous
ventilator triggering, situations in which respiratory variation of arterial
pulse pressure lost any predictive ability. Probably descending aortic blood
flow was a better measure of cardiac output than pulse pressure, volume
responsiveness was better predicted by PLR-induced changes in aortic blood flow
than by PLR-induced changes in arterial pulse pressure. In another series of
patients fully adapted to their ventilator, Lafanechere et al. [17•] also found
that fluid responsiveness could be reliably predicted by the response of
descending aortic blood flow to PLR.
Since the maximal hemodynamic effects of PLR occurred within the first minute of
leg elevation [18••], it is important to assess these effects with a method able
to track changes in cardiac output or stroke volume on a real-time basis. In
this regard, the response of descending aortic blood flow (measured by
esophageal Doppler) to PLR [17•,18••] as well as the response of the
velocity–time integral (measured by transthoracic echocardiography) [39] to PLR
have been demonstrated to be helpful in predicting the response to volume
administration in patients with spontaneous
17• Lafanechere A, Pene F, Goulenok C, et al. Changes in aortic blood flow
induced by passive leg raising predict fluid responsiveness in critically ill
patients. Crit Care 2006; 10:R132. Mount Sinai Serials This study confirms the
reliability of the PLR test for predicting volume responsiveness by means of
esophageal Doppler monitoring, as demonstrated by Monnet et al. [18••]. [Context
Link]
18•• Monnet X, Rienzo M, Osman D, et al. Passive leg raising predicts fluid
responsiveness in the critically ill. Crit Care Med 2006; 34:1402–1407. Ovid
Full Text Mount Sinai Serials In 71 patients with acute circulatory failure,
increases in the aortic blood flow measured by esophageal Doppler by more than
10% allows one to predict volume responsiveness with a sensitivity of 97% and a
specificity of 94%. Importantly, in a subgroup of patients with spontaneous
breathing activity or cardiac arrhythmias, PLR kept its full predictive value
while the respiratory variation of pulse pressure was ineffective for predicting
volume responsiveness. [Context Link]
38 Boulain T, Achard JM, Teboul JL, et al. Changes in BP induced by passive leg raising predict response to fluid loading in critically ill patients. Chest 2002; 121:1245–1252. Mount Sinai Serials Bibliographic Links [Context Link]
Passive leg raising-induced changes in mean radial artery pressure can be used to assess preload dependence
Critical Care 2007, 11(Suppl 2):P307
(Chest. 2002;121:1245-1252.)
Changes in BP Induced by Passive Leg Raising Predict Response to Fluid Loading
in Critically Ill Patients*
Monnet, Xavier MD, PhD; Rienzo, Mario MD; Osman, David MD; Anguel, Nadia MD; Richard, Christian MD; Pinsky, Michael R. MD, Dr hc; Teboul, Jean-Louis MD, PhD
Issue:Passive leg raising predicts fluid responsiveness in the critically ill *
critical care medicine
>9% change in pulse pressure or > 10% in SV, by PLR predicted volume responsiveness in non-intubated spont breathing patients. (CCM 2010,38:819)
To know if your passive leg raise is accurate, you need to see the CVP increase by at least 2 mm Hg. If this occurs pulse pressure changes are accurate (8%)
(Inten Care Med 2010;36:940)
If there is not an icrease, then you need a stroke volume marker and can't use PP
LR +9, LR-0.14
predicting fluid responsiveness in the OR (Br J Anaes 2007;98(4):545)
delta down component of SPV
minimal resp spv=not fluid responsive
Editorial on pulse pressure variation
(Chest 2002;121:2000)
Article on Non-Invasive (Br J Anaesth 2006;97:808)
(Can J Anesth 2003;50:10)
American Journal of Critical Care. 2005;14: 364-368
Use of the Trendelenburg Position as the Resuscitation Position: To T or Not to T?
Expiratory Hold to Predict Volume Responsiveness (Crit Care Med 2009;37(3):951)
15 second expiratory hold
maximal change during last five seconds = test
15% change in arterial pulse pressure predicts volume expansion
Dynamic changes can be false if there is RV dysfunction (will yield false positives) as the PPV means the LA needs more fluid but giving it in the face of the RV failure will not get the fluid to the LA. Put the patient on 10 ml/kg and sedate them. (CCM 2009;37(9):2642)
Critical Care 2005;9
The mean systemic pressure is the theoretical pressure value that would be observed in the overall circulatory system under zero flow conditions, assumed to be pressure in the right atrium
MAP=(HR x SV x SVR) -mRAP
13% variation discerned between responders and non to add. fluid resus
Pre-ejection period variations predict the fluid responsiveness of septic
ventilated patients
[Clinical Investigations]
Feissel, Marc MD; Badie, Julio MD; Merlani, Paolo G. MD; Faller, Jean-Pierre MD;
Bendjelid, Karim MD, MS
Conclusions: The present study found [DELTA]PEPKT and [DELTA]PEPPLET to be as
accurate as [DELTA]PP in the prediction of fluid responsiveness in mechanically
ventilated septic patients.
Crit Care Med 2005;33(11):2534
Study comparing static pressure markers to Pulse Pressure variation and new proprietary Resp Systolic Variation Test (Br J Anaes 2005;95(6):746)
Driving pressure > 20 is probably necessary to get good PPV (Inten Care Med Volume 36, Number 3 / March, 2010:1432)
use of doppler ultrasound variation of brachial artery in response to ventilation
Monge García et al. Critical Care 2009 13:R142
Three diastolic filling patterns as assessed by Doppler echocardiography. A = late transmitral velocity occurring with atrial contraction; AF = atrial fibrillation; DTE = deceleration time of early transmitral velocity; E = early transmitral velocity; EA = ratio of early to late transmitral velocity.
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