Volume responsiveness assessed by passive leg raising and a fluid challenge: a critical review focused on mean systemic filling pressure

Abstract

This review applied cardiovascular principles relevant to the physiology of venous return in interpreting studies on the utility of a passive leg-raising manoeuvre to identify patients who do (responders) or do not respond to a subsequent intravenous volume challenge with an increase in cardiac output. Values for cardiac output, mean arterial and central venous pressure, and the calculated cardiovascular variables mean systemic filling pressure analogue, heart efficiency, cardiac power indexed by volume state and volume efficiency, before and after passive leg raising as well as before and after fluid volume challenge, were extracted from published studies. Eleven studies including 572 patients and 52% responders were analysed. Cardiac output increased by 12% in responders during passive leg raising and by 22% following a volume challenge. No statistically significant differences were found between responders and non-responders in cardiac output, mean arterial or central venous pressure before the passive leg-raising manoeuvre or the volume challenge. In contrast, the calculated mean (SD) systemic filling pressure analogue, reflecting the intravascular volume, was significantly lower in responders (14.2 (1.8) mmHg) than non-responders (17.5 (3.4) mmHg; p = 0.007) before the passive leg-raising manoeuvre, as well as before fluid volume challenge (14.6 (2.2) mmHg vs. 17.6 (3.5) mmHg, respectively; p = 0.02). The scalar measure volume efficiency was higher in responders at 0.35 compared with non-responders at 0.10. Non-responders also demonstrated deteriorating heart efficiency of -15% and cardiac power of -7% when given an intravenous fluid volume challenge. The results demonstrate that the calculation of mean systemic filling pressure analogue and derived variables can identify patients likely to respond to a fluid volume challenge and provides scalar results rather than merely a dichotomous outcome of responder or non-responder.

Volume status and volume responsiveness in postoperative cardiac surgical patients: An observational, multicentre cohort study

“…The range of P msa is furthermore similar to the mean systemic filling pressure of 18‐21 mm Hg obtained from successive inspiratory hold manoeuvres in patients following cardiac surgery 20,23 . The increased P msa following boluses is consistent with responses to volume loading reported earlier following cardiac surgery, 11‐13,20,22,23 hepatic surgery 24 as well as in general ICU patients 25 . Taken together, these studies lend credibility to the concept of using P msa to assess volume state and responses to increased intravascular filling.…”

“…The E vol demonstrated the best association with volume responsiveness which is not unexpected given that its calculation incorporates the change in VRdP over the change in P msa . The AUROC for E vol was comparable to that reported in a review of passive leg raising manoeuvres to identify volume responders 25 . Overall, E vol was the only variable associated with CO responsiveness in the hierarchical clustering analysis.…”

Physiology-guided management of hemodynamics in acute respiratory distress syndrome

“…This observation should prompt the clinician to assess RV function with echocardiography and/or to track the changes in PPV during passive leg raising (PLR). A decrease in PPV during PLR suggests fluid responsiveness, whereas no change could indicate the presence of RV afterload dependence (40).…”

Comparison of echocardiographic and invasive measures of volaemia and cardiac performance in critically ill patients

“…where P ms is mean systemic filling pressure and CVP is central venous pressure; E h is a dimensionless ratio between zero and one, where zero describes a "no flow" state and one describes an optimal heart performance, with a typically observed range between 0.3 and 0.5 in critically ill patients 19,23 . A physician qualified in transthoracic echocardiography (Advanced Transthoracic Echocardiography training, Level 2a or higher) 24 performed all echocardiographic measurements (SC2000, Siemens Healthcare GmbH, Erlangen, Germany, or Sparq, Philips Ultrasound, Bothell, WA, USA).…”