title: Brachial cuff measurements of blood pressure during passive leg raising for fluid responsiveness prediction.
abstract: OBJECTIVE
  The passive leg raising maneuver (PLR) for fluid responsiveness testing relies on cardiac output (CO) measurements or invasive measurements of arterial pressure (AP) whereas the initial hemodynamic management during shock is often based solely on brachial cuff measurements. We assessed PLR-induced changes in noninvasive oscillometric readings to predict fluid responsiveness.
  
  
  METHODS
  Multicentre interventional study.
  
  
  METHODS
  In ICU sedated patients with circulatory failure, AP (invasive and noninvasive readings) and CO measurements were performed before, during PLR (trunk supine, not modified) and after 500-mL volume expansion. Areas under the ROC curves (AUC) were determined for fluid responsiveness (>10% volume expansion-induced increase in CO) prediction.
  
  
  RESULTS
  In 112 patients (19% with arrhythmia), changes in noninvasive systolic AP during PLR (noninvasiveΔ(PLR)SAP) only predicted fluid responsiveness (cutoff 17%, n=21, positive likelihood ratio [LR] of 26 [18-38]), not unresponsiveness. If PLR-induced change in central venous pressure (CVP) was at least of 2 mm Hg (n=60), suggesting that PLR succeeded in altering cardiac preload, noninvasiveΔ(PLR)SAP performance was good: AUC of 0.94 [0.85-0.98], positive and negative LRs of 5.7 [4.6-6.8] and 0.07 [0.009-0.5], respectively, for a cutoff of 9%. Of note, invasive AP-derived indices did not outperform noninvasiveΔ(PLR)SAP.
  
  
  CONCLUSIONS
  Regardless of CVP (i.e., during "blind PLR"), noninvasiveΔ(PLR)SAP more than 17% reliably identified fluid responders. During "CVP-guided PLR", in case of sufficient change in CVP, noninvasiveΔ(PLR)SAP performed better (cutoff of 9%). These findings, in sedated patients who had already undergone volume expansion and/or catecholamines, have to be verified during the early phase of circulatory failure (before an arterial line and/or a CO measuring device is placed).
authors.affiliation: Service de réanimation médicale et maladies infectieuses, hôpital Bichat-Claude Bernard, Assistance publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris cedex 18, France. lakhal_karim@yahoo.fr
authors.forename: K
authors.initials: K
authors.lastname: Lakhal
authors.forename: S
authors.initials: S
authors.lastname: Ehrmann
authors.forename: D
authors.initials: D
authors.lastname: Benzekri-Lefèvre
authors.forename: I
authors.initials: I
authors.lastname: Runge
authors.forename: A
authors.initials: A
authors.lastname: Legras
authors.forename: P-F
authors.initials: PF
authors.lastname: Dequin
authors.forename: E
authors.initials: E
authors.lastname: Mercier
authors.forename: M
authors.initials: M
authors.lastname: Wolff
authors.forename: B
authors.initials: B
authors.lastname: Régnier
authors.forename: T
authors.initials: T
authors.lastname: Boulain
mesh_terms: D000368:Aged; D019540:Area Under Curve; D001145:Arrhythmias, Cardiac / Q000150:complications / Q000628:therapy; D001794:Blood Pressure / Q000502:physiology*; D001795:Blood Pressure Determination / Q000379:methods*; D002302:Cardiac Output / Q000502:physiology; D002496:Central Venous Pressure / Q000502:physiology; D003422:Critical Care; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D007866:Leg / Q000098:blood supply / Q000502:physiology*; D008297:Male; D008875:Middle Aged; D011187:Posture / Q000502:physiology; D011237:Predictive Value of Tests; D012372:ROC Curve; D012039:Regional Blood Flow / Q000502:physiology; D012769:Shock / Q000175:diagnosis / Q000628:therapy