Changes in stroke volume induced by passive leg raising in spontaneously breathing patients: comparison between echocardiography and Vigileo/FloTrac device

Matthieu Biais, Lionel Vidil, Philippe Sarrabay, Vincent Cottenceau, Philippe Revel, François Sztark, Matthieu Biais, Lionel Vidil, Philippe Sarrabay, Vincent Cottenceau, Philippe Revel, François Sztark

Abstract

Introduction: Passive leg raising (PLR) is a simple reversible maneuver that mimics rapid fluid loading and increases cardiac preload. The effects of this endogenous volume expansion on stroke volume enable the testing of fluid responsiveness with accuracy in spontaneously breathing patients. However, this maneuver requires the determination of stroke volume with a fast-response device, because the hemodynamic changes may be transient. The Vigileo monitor (Vigileo; Flotrac; Edwards Lifesciences, Irvine, CA, USA) analyzes systemic arterial pressure wave and allows continuous stroke volume monitoring. The aims of this study were (i) to compare changes in stroke volume induced by passive leg raising measured with the Vigileo device and with transthoracic echocardiography and (ii) to compare their ability to predict fluid responsiveness.

Methods: Thirty-four patients with spontaneous breathing activity and considered for volume expansion were included. Measurements of stroke volume were obtained with transthoracic echocardiography (SV-TTE) and with the Vigileo (SV-Flotrac) in a semi-recumbent position, during PLR and after volume expansion (500 ml saline). Patients were responders to volume expansion if SV-TTE increased > or = 15%.

Results: Four patients were excluded. No patients received vasoactive drugs. Seven patients presented septic hypovolemia. PLR-induced changes in SV-TTE and in SV-Flotrac were correlated (r2 = 0.56, P < 0.0001). An increase in SV-TTE > or = 13% during PLR was predictive of response to volume expansion with a sensitivity of 100% and a specificity of 80%. An increase in SV-Flotrac > or =16% during PLR was predictive of response to volume expansion with a sensitivity of 85% and a specificity of 90%. There was no difference between the area under the ROC curve for PLR-induced changes in SV-TTE (AUC = 0.96 +/- 0.03) or SV-Flotrac (AUC = 0.92 +/- 0.05). Volume expansion-induced changes in SV-TTE correlated with volume expansion-induced changes in SV-Flotrac (r2 = 0.77, P < 0.0001). In all patients, the highest plateau value of SV-TTE recorded during PLR was obtained within the first 90 s following leg elevation, whereas it was 120 s for SV-Flotrac.

Conclusions: PLR-induced changes in SV-Flotrac are able to predict the response to volume expansion in spontaneously breathing patients without vasoactive support.

Figures

Figure 1
Figure 1
PLR-induced changes in SV-TTE and in SV-Flotrac in responders and non-responders. Box plots and individual values of passive leg raising (PLR)-induced changes in stroke volume measured with transthoracic echocardiography (SV-TTE) and with Vigileo™ (SV-Flotrac) in responders (Rs) and in non-responders (NRs).
Figure 2
Figure 2
Relation between PLR-induced changes in SV-TTE and SV-Flotrac. Relation between passive leg raising (PLR)-induced changes in stroke volume measured with transthoracic echocardiography (SV-TTE) and with Vigileo™ (SV-FloTrac).
Figure 3
Figure 3
Relation between VE-induced changes in SV-TTE and SV-Flotrac. Relation between volume expansion (VE)-induced changes in stroke volume measured with transthoracic echocardiography (SV-TTE) and with Vigileo™ (SV-FloTrac).
Figure 4
Figure 4
ROC curves for predicting response to volume expansion. Receiver operating characteristic (ROC) curves comparing the ability of passive leg raising (PLR)-induced changes in stroke volume measured with transthoracic echocardiography (SV-TTE) and with Vigileo™ (SV-Flotrac) to discriminate responders and non-responders following volume expansion.
Figure 5
Figure 5
Comparison between SV-TTE and SV-Flotrac at baseline, during PLR, before VE and after VE. Bland-Altman plots between stroke volume measured by transthoracic echocardiography (SV-TTE) and by Vigileo™ (SV-Flotrac) at baseline, during passive leg raising, before and after volume expansion. The continuous lines show the mean difference (bias) and the dotted lines show the 95% limits of agreement (two standard deviations).

References

    1. Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest. 2002;121:2000–2008. doi: 10.1378/chest.121.6.2000.
    1. Osman D, Ridel C, Ray P, Monnet X, Anguel N, Richard C, Teboul JL. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med. 2007;35:64–68. doi: 10.1097/01.CCM.0000249851.94101.4F.
    1. Hofer CK, Muller SM, Furrer L, Klaghofer R, Genoni M, Zollinger A. Stroke volume and pulse pressure variation for prediction of fluid responsiveness in patients undergoing off-pump coronary artery bypass grafting. Chest. 2005;128:848–854. doi: 10.1378/chest.128.2.848.
    1. Reuter DA, Felbinger TW, Schmidt C, Kilger E, Goedje O, Lamm P, Goetz AE. Stroke volume variations for assessment of cardiac responsiveness to volume loading in mechanically ventilated patients after cardiac surgery. Intensive Care Med. 2002;28:392–398. doi: 10.1007/s00134-002-1211-z.
    1. Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest. 2001;119:867–873. doi: 10.1378/chest.119.3.867.
    1. Michard F, Boussat S, Chemla D, Anguel N, Mercat A, Lecarpentier Y, Richard C, Pinsky MR, Teboul JL. Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med. 2000;162:134–138.
    1. Michard F, Chemla D, Richard C, Wysocki M, Pinsky MR, Lecarpentier Y, Teboul JL. Clinical use of respiratory changes in arterial pulse pressure to monitor the hemodynamic effects of PEEP. Am J Respir Crit Care Med. 1999;159:935–939.
    1. Tavernier B, Makhotine O, Lebuffe G, Dupont J, Scherpereel P. Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced hypotension. Anesthesiology. 1998;89:1313–1321. doi: 10.1097/00000542-199812000-00007.
    1. Biais M, Nouette-Gaulain K, Cottenceau V, Revel P, Sztark F. Uncalibrated pulse contour-derived stroke volume variation predicts fluid responsiveness in mechanically ventilated patients undergoing liver transplantation. Br J Anaesth. 2008;101:761–768. doi: 10.1093/bja/aen277.
    1. Jabot J, Teboul JL, Richard C, Monnet X. Passive leg raising for predicting fluid responsiveness: importance of the postural change. Intensive Care Med. 2009;35:85–90. doi: 10.1007/s00134-008-1293-3.
    1. Caille V, Jabot J, Belliard G, Charron C, Jardin F, Vieillard-Baron A. Hemodynamic effects of passive leg raising: an echocardiographic study in patients with shock. Intensive Care Med. 2008;34:1239–1245. doi: 10.1007/s00134-008-1067-y.
    1. Lamia B, Ochagavia A, Monnet X, Chemla D, Richard C, Teboul JL. Echocardiographic prediction of volume responsiveness in critically ill patients with spontaneously breathing activity. Intensive Care Med. 2007;33:1125–1132. doi: 10.1007/s00134-007-0646-7.
    1. Monnet X, Rienzo M, Osman D, Anguel N, Richard C, Pinsky MR, Teboul JL. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med. 2006;34:1402–1407. doi: 10.1097/01.CCM.0000215453.11735.06.
    1. Lafanechere A, Pene F, Goulenok C, Delahaye A, Mallet V, Choukroun G, Chiche JD, Mira JP, Cariou A. Changes in aortic blood flow induced by passive leg raising predict fluid responsiveness in critically ill patients. Crit Care. 2006;10:R132. doi: 10.1186/cc5044.
    1. Boulain T, Achard JM, Teboul JL, Richard C, Perrotin D, Ginies G. Changes in BP induced by passive leg raising predict response to fluid loading in critically ill patients. Chest. 2002;121:1245–1252. doi: 10.1378/chest.121.4.1245.
    1. Monnet X, Teboul JL. Passive leg raising. Intensive Care Med. 2008;34:659–663. doi: 10.1007/s00134-008-0994-y.
    1. Thiel SW, Kollef MH, Isakow W. Non-invasive stroke volume measurement and passive leg raising predict volume responsiveness in medical ICU patients: an observational cohort study. Crit Care. 2009;13:R111. doi: 10.1186/cc7955.
    1. Manecke GR. Edwards FloTrac sensor and Vigileo monitor: easy, accurate, reliable cardiac output assessment using the arterial pulse wave. Expert Rev Med Devices. 2005;2:523–527. doi: 10.1586/17434440.2.5.523.
    1. Langewouters G, Wesseling K, Goedhard W. The pressure dependent dynamic elasticity of 35 thoracic and 16 abdominal human aortas in vitro described by a five component model. J Biomech. 1985;18:613–620. doi: 10.1016/0021-9290(85)90015-6.
    1. Hanley JA, McNeil BJ. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology. 1983;148:839–843.
    1. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;1:307–310. doi: 10.1016/S0140-6736(86)91008-1.
    1. Critchley LA, Critchley JA. A meta-analysis of studies using bias and precision statistics to compare cardiac output measurement techniques. J Clin Monit Comput. 1999;15:85–91. doi: 10.1023/A:1009982611386.
    1. Biais M, Nouette-Gaulain K, Cottenceau V, Vallet A, Cochard JF, Revel P, Sztark F. Cardiac output measurement in patients undergoing liver transplantation: pulmonary artery catheter versus uncalibrated arterial pressure waveform analysis. Anesth Analg. 2008;106:1480–1486. doi: 10.1213/ane.0b013e318168b309.
    1. Compton FD, Zukunft B, Hoffmann C, Zidek W, Schaefer JH. Performance of a minimally invasive uncalibrated cardiac output monitoring system (Flotrac/Vigileo) in haemodynamically unstable patients. Br J Anaesth. 2008;100:451–456. doi: 10.1093/bja/aem409.
    1. de Waal EE, Kalkman CJ, Rex S, Buhre WF. Validation of a new arterial pulse contour-based cardiac output device. Crit Care Med. 2007;35:1904–1909. doi: 10.1097/01.CCM.0000275429.45312.8C.
    1. Sakka SG, Kozieras J, Thuemer O, van Hout N. Measurement of cardiac output: a comparison between transpulmonary thermodilution and uncalibrated pulse contour analysis. Br J Anaesth. 2007;99:337–342. doi: 10.1093/bja/aem177.
    1. Mayer J, Boldt J, Wolf MW, Lang J, Suttner S. Cardiac output derived from arterial pressure waveform analysis in patients undergoing cardiac surgery: validity of a second generation device. Anesth Analg. 2008;106:867–872. doi: 10.1213/ane.0b013e318161964d. table of contents.
    1. Biancofiore G, Critchley LA, Lee A, Bindi L, Bisa M, Esposito M, Meacci L, Mozzo R, DeSimone P, Urbani L, Filipponi F. Evaluation of an uncalibrated arterial pulse contour cardiac output monitoring system in cirrhotic patients undergoing liver surgery. Br J Anaesth. 2009;102:47–54. doi: 10.1093/bja/aen343.
    1. Senn A, Button D, Zollinger A, Hofer CK. Assessment of cardiac output changes using a modified FloTrac/Vigileo algorithm in cardiac surgery patients. Crit Care. 2009;13:R32. doi: 10.1186/cc7739.
    1. Biais M, Nouette-Gaulain K, Roullet S, Quinart A, Revel P, Sztark F. A comparison of stroke volume variation measured by Vigileo/FloTrac system and aortic Doppler echocardiography. Anesth Analg. 2009;109:466–469. doi: 10.1213/ane.0b013e3181ac6dac.
    1. Maizel J, Airapetian N, Lorne E, Tribouilloy C, Massy Z, Slama M. Diagnosis of central hypovolemia by using passive leg raising. Intensive Care Med. 2007;33:1133–1138. doi: 10.1007/s00134-007-0642-y.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren