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Passive leg raising for predicting fluid responsiveness: a systematic review and meta-analysis

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Abstract

Purpose

We performed a systematic review and meta-analysis of studies investigating the passive leg raising (PLR)-induced changes in cardiac output (CO) and in arterial pulse pressure (PP) as predictors of fluid responsiveness in adults.

Methods

MEDLINE, EMBASE and Cochrane Database were screened for relevant original and review articles. The meta-analysis determined the pooled area under the ROC curve, the sensitivity, specificity and threshold for the PLR test when assessed with CO and PP.

Results

Twenty-one studies (991 adult patients, 995 fluid challenges) were included. CO was measured by echocardiography in six studies, calibrated pulse contour analysis in six studies, bioreactance in four studies, oesophageal Doppler in three studies, transpulmonary thermodilution or pulmonary artery catheter in one study and suprasternal Doppler in one study. The pooled correlation between the PLR-induced and the fluid-induced changes in CO was 0.76 (0.73–0.80). For the PLR-induced changes in CO, the pooled sensitivity was 0.85 (0.81–0.88) and the pooled specificity was 0.91 (0.88–0.93). The area under the ROC curve was 0.95 ± 0.01. The best threshold was a PLR-induced increase in CO ≥10 ± 2 %. For the PLR-induced changes in PP (8 studies, 432 fluid challenges), the pooled sensitivity was 0.56 (0.49–0.53), the pooled specificity was 0.83 (0.77–0.88) and the pooled area under the ROC curve was 0.77 ± 0.05. Sensitivity and subgroup analysis were consistent with the primary analysis.

Conclusions

PLR-induced changes in CO very reliably predict the response of CO to volume expansion in adults with acute circulatory failure. When PLR effects are assessed by changes in PP, the specificity of the PLR test remains acceptable but its sensitivity is poor.

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Authors and Affiliations

  1. Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, 78, Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France

    Xavier Monnet & Jean-Louis Teboul

  2. Faculté de Médecine Paris-Sud, Inserm UMR S_999, Univ Paris-Sud, Le Kremlin-Bicêtre, France

    Xavier Monnet & Jean-Louis Teboul

  3. Division of Pulmonary and Critical Care Medicine, Department of Medicine, Eastern Virginia Medical School, Norfolk, VA, USA

    Paul Marik

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  1. Xavier Monnet
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  2. Paul Marik
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  3. Jean-Louis Teboul
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Correspondence to Xavier Monnet.

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Conflicts of interest

Jean-Louis Teboul and Xavier Monnet are members of the Medical Advisory Board of Maquet. They are the authors of the majority of the studies included in this meta-analysis. Paul E Marik has no conflicts to disclose.

Additional information

Take-home message: In this meta-analysis of 21 studies including 991 adult patients in whom 995 fluid challenges were performed, total, we found that the changes in cardiac output induced by a passive leg raising test are highly reliable in predicting fluid responsiveness. When its effects were assessed by changes in arterial pulse pressure, the specificity of passive leg raising remains good but its sensitivity is poor.

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Monnet, X., Marik, P. & Teboul, JL. Passive leg raising for predicting fluid responsiveness: a systematic review and meta-analysis. Intensive Care Med 42, 1935–1947 (2016). https://doi.org/10.1007/s00134-015-4134-1

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