title: Passive leg raise testing effectively reduces fluid administration in septic shock after correction of non-compliance to test results.
abstract: BACKGROUND
  Fluid resuscitation is considered a cornerstone of shock treatment, but recent data have underlined the potential hazards of fluid overload. The passive leg raise (PLR) test has been introduced as one of many strategies to predict 'fluid responsiveness.' The use of PLR testing is applicable to a wide range of clinical situations and has the potential to reduce fluid administration, since PLR testing is based upon (reversible) autotransfusion. Despite these theoretical advantages, data on the net effect on fluid balance as a result of PLR testing remain scarce.
  
  
  METHODS
  We performed a prospective single-center multi-step interventional study in patients with septic shock to evaluate the effect of implementation of PLR testing on the fluid balance (FB) 48 hours after ICU admission. All patients were equipped with a PiCCO®device for pulse contour analysis to guide fluid administration. An increase in stroke volume (SV) ≥ 10% was considered a positive test result.
  
  
  RESULTS
  Before introduction of PLR testing, 21 patients were prospectively included in period 1 with a median FB of 4.8 [3.3-7.8]L. After an extensive training program, PLR testing was introduced and 20 patients were included in period 2. Median FB was 4.4 [3.3-7.5]L and did not differ from period 1 (p = 0.72). Further analysis revealed that non-compliance to the PLR test result was 44%. These findings were discussed with all ICU doctors and nurses. By consensus, non-compliance to the PLR test result was identified as the main reason for unsuccessful implementation of PLR testing. After this evaluation, 19 patients were included in period 3 under equal conditions as in period 2. In this period, median FB was 3.1 [1.5-4.9]L and significantly reduced in comparison with periods 1 and 2 (p = 0.016 and p = 0.023, respectively). Non-compliance was 9% and significantly lower than in period 2 (p = 0.009).
  
  
  CONCLUSIONS
  Implementation of PLR testing in patients with septic shock reduced fluid administration in the first 48 hours of ICU admission significantly and substantially. To achieve this endpoint, substantial non-compliance of ICU team members had to be addressed. Fluid administration despite a negative PLR test was the most common form of non-compliance.
authors.affiliation: Department of Intensive Care, Medical Centre Leeuwarden, Henrie Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands.
authors.forename: Arjanne
authors.initials: A
authors.lastname: Rameau
authors.affiliation: Department of Intensive Care, Medical Centre Leeuwarden, Henrie Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands.
authors.forename: Eldert
authors.initials: E
authors.lastname: de With
authors.affiliation: Department of Intensive Care, Medical Centre Leeuwarden, Henrie Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands. e.boerma@chello.nl.
authors.forename: Evert Christiaan
authors.initials: EC
authors.lastname: Boerma
keywords: Fluid administration; Implementation; Knowledge-to-care gap; Non-compliance; Passive leg raise test; Sepsis