title: The reliability and validity of passive leg raise and fluid bolus to assess fluid responsiveness in spontaneously breathing emergency department patients.
abstract: OBJECTIVE
  We investigated the reproducibility of passive leg raise (PLR) and fluid bolus (BOLUS) using the Non-Invasive Cardiac Output Monitor (NICOM; Cheetah Medical, Tel Aviv, Israel) for assessment of fluid responsiveness (FR) in spontaneously breathing emergency department (ED) patients.
  
  
  METHODS
  Prospective, observational study of a convenience sample of adult ED patients receiving intravenous fluid bolus. We assessed stroke volume (SV) using NICOM and obtained results from PLR, where the head of the bed was changed from semirecumbent to supine while the patients' legs raised to 45° for 3 minutes. Fluid bolus was defined as 5 mL/kg normal saline infusion. Maximal increase in SV was recorded. Fluid responsiveness was defined as an increase of SV greater than 10% from baseline. We obtained 4 consecutive responses for each patient; PLR1, PLR2, BOLUS1 separated each by 10 minutes, and BOLUS2 initiated immediately after the end of BOLUS1. We calculated κ statistics, correlation coefficients, and odds ratios with 95% confidence interval and Bland-Altman plots.
  
  
  RESULTS
  We enrolled 109 patients enrolled in this study. The 2 PLRs were significantly correlated (r = 0.78, P < .001) with κ = 0.46 for FR (P < .001). The 2 BOLUSES less strongly correlated (r = 0.14, P = .001) and κ = 0.06 for FR (P < .001). Patients who were responsive to PLR1 had 9.5 (3.6-25) odds of being FR for PLR2, whereas those responsive to BOLUS1 had a 1.8 (0.76-4.3) increased odds of FR for BOLUS2.
  
  
  CONCLUSIONS
  In conclusion, we have found PLR as measured by the NICOM to be a promising tool for the evaluation of SV responsiveness. It was feasible for use in the ED, and the data suggest that the PLR technique may be more reproducible than the fluid bolus technique for assessing volume responsiveness.
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark. Electronic address: Duus.nicolaj@gmail.com.
authors.forename: Nicolaj
authors.initials: N
authors.lastname: Duus
authors.affiliation: Duke University, Division of Emergency Medicine, Duke University, Durham, North Carolina.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Shogilev
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.
authors.forename: Simon
authors.initials: S
authors.lastname: Skibsted
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
authors.forename: Hendrik W
authors.initials: HW
authors.lastname: Zijlstra
authors.affiliation: Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
authors.forename: Emily
authors.initials: E
authors.lastname: Fish
authors.affiliation: Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
authors.forename: Achikam
authors.initials: A
authors.lastname: Oren-Grinberg
authors.affiliation: Clinical Research Center, Soroka University Medical Center Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel.
authors.forename: Yotam
authors.initials: Y
authors.lastname: Lior
authors.affiliation: Clinical Research Center, Soroka University Medical Center Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel.
authors.forename: Victor
authors.initials: V
authors.lastname: Novack
authors.affiliation: Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Talmor
authors.affiliation: Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.
authors.forename: Hans
authors.initials: H
authors.lastname: Kirkegaard
authors.affiliation: Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
authors.forename: Nathan I
authors.initials: NI
authors.lastname: Shapiro
mesh_terms: D000328:Adult; D000368:Aged; D002302:Cardiac Output / Q000502:physiology*; D016001:Confidence Intervals; D004636:Emergency Service, Hospital; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans; D007866:Leg; D017770:Lifting; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000295:instrumentation / Q000379:methods; D016017:Odds Ratio; D056888:Patient Positioning / Q000379:methods*; D011446:Prospective Studies; D015203:Reproducibility of Results; D012119:Respiration; D012965:Sodium Chloride / Q000008:administration & dosage; D013318:Stroke Volume / Q000502:physiology; D013997:Time Factors
chemical_list: D012965:Sodium Chloride
keywords: Fluid bolus; Fluid responsiveness; Fluid resuscitation; Noninvasive monitoring; Passive leg raise