Passive leg raising-induced changes in pulse pressure variation to assess fluid responsiveness in mechanically ventilated patients: a multicentre prospective observational study

Jihad Mallat; Marc-Olivier Fischer; Maxime Granier; Christophe Vinsonneau; Marie Jonard; Yazine Mahjoub; Fawzi Ali Baghdadi; Sébastien Préau; Fabien Poher; Olivier Rebet; Belaid Bouhemad; Malcolm Lemyze; Mehdi Marzouk; Emmanuel Besnier; Fadi Hamed; Nadeem Rahman; Osama Abou-Arab; Pierre-Grégoire Guinot

doi:10.1016/j.bja.2022.04.031

Passive leg raising-induced changes in pulse pressure variation to assess fluid responsiveness in mechanically ventilated patients: a multicentre prospective observational study

Br J Anaesth. 2022 Sep;129(3):308-316. doi: 10.1016/j.bja.2022.04.031. Epub 2022 Jul 14.

Authors

Jihad Mallat¹, Marc-Olivier Fischer², Maxime Granier³, Christophe Vinsonneau⁴, Marie Jonard⁵, Yazine Mahjoub⁶, Fawzi Ali Baghdadi⁷, Sébastien Préau⁸, Fabien Poher⁹, Olivier Rebet¹⁰, Belaid Bouhemad¹¹, Malcolm Lemyze³, Mehdi Marzouk⁴, Emmanuel Besnier¹², Fadi Hamed¹³, Nadeem Rahman¹³, Osama Abou-Arab¹⁴, Pierre-Grégoire Guinot¹⁵

Affiliations

¹ Department of Critical Care Medicine, Arras Hospital, Arras, France; Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Normandy University, UNICAEN, Ecole Doctorale NBISE 497, Caen, France. Electronic address: mallatjihad@gmail.com.
² Normandy University, UNICAEN, CHU de Caen Normandie, Ecole Doctorale NBISE 497, Service d'Anesthésie Réanimation, Caen, France.
³ Department of Critical Care Medicine, Arras Hospital, Arras, France.
⁴ Intensive Care Unit, Hôpital de Béthune, Beuvry, France.
⁵ Department of Critical Care Medicine, Amiens University Medical Centre, Amiens, France.
⁶ Cardiac Vascular Thoracic and Respiratory Intensive Care Unit, Department of Anesthesia and Intensive Care, Amiens University Medical Centre, Amiens, France.
⁷ Department of Critical Care Medicine, Intensive Care Unit, Centre Hospitalier de Cambrai, Cambrai, France.
⁸ Division of Intensive Care, Inserm, Institut Pasteur de Lille, U1167, University of Lille, CHU Lille, Lille, France.
⁹ Intensive Care Unit, Centre Hospitalier de Boulogne Sur Mer, Boulogne Sur Mer, France.
¹⁰ Cardiac Vascular Intensive Care Unit, Schaffner Hospital, Lens, France.
¹¹ Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France.
¹² Department of Anesthesiology and Critical Care, Rouen University Hospital, Rouen, France.
¹³ Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.
¹⁴ Anesthesia and Critical Care department, Amiens Hospital University, Amiens, France.
¹⁵ Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, Dijon, France.

PMID: 35842352
DOI: 10.1016/j.bja.2022.04.031

Abstract

Background: Passive leg raising-induced changes in cardiac index can be used to predict fluid responsiveness. We investigated whether passive leg raising-induced changes in pulse pressure variation (ΔPPV_PLR) can also predict fluid responsiveness in mechanically ventilated patients.

Methods: In this multicentre prospective observational study, we included 270 critically ill patients on mechanical ventilation in whom volume expansion was indicated because of acute circulatory failure. We did not include patients with cardiac arrythmias. Cardiac index and PPV were measured before/during a passive leg raising test and before/after volume expansion. A volume expansion-induced increase in cardiac index of >15% defined fluid responsiveness. To investigate whether ΔPPV_PLR can predict fluid responsiveness, we determined areas under the receiver operating characteristic curves (AUROCs) and grey zones for relative and absolute ΔPPV_PLR.

Results: Of the 270 patients, 238 (88%) were on controlled mechanical ventilation with no spontaneous breathing activity and 32 (12%) were on pressure support ventilation. The median tidal volume was 7.1 (inter-quartile range [IQR], 6.6-7.6) ml kg^-1 ideal body weight. One hundred sixty-four patients (61%) were fluid responders. Relative and absolute ΔPPV_PLR predicted fluid responsiveness with an AUROC of 0.92 (95% confidence interval [95% CI], 0.88-0.95; P<0.001) each. The grey zone for relative and absolute ΔPPV_PLR included 4.8% and 22.6% of patients, respectively. These results were not affected by ventilatory mode and baseline characteristics (type of shock, centre, vasoactive treatment).

Conclusions: Passive leg raising-induced changes in pulse pressure variation accurately predict fluid responsiveness with a small grey zone in critically ill patients on mechanical ventilation.

Clinical trial registration: NCT03225378.

Keywords: acute circulatory failure; cardiac output; fluid challenge; grey zone; pulse pressure variation; sepsis.

Publication types

Multicenter Study
Observational Study

MeSH terms

Blood Pressure
Cardiac Output
Critical Illness / therapy
Fluid Therapy* / methods
Hemodynamics
Humans
Leg
Prospective Studies
Respiration, Artificial*
Stroke Volume

Associated data

ClinicalTrials.gov/NCT03225378