Assessment Of Volume Responsiveness By Passive Leg Raising Test In Pediatric Shock – Preliminary Observations

1. Assessment Of Volume
Responsiveness By Passive Leg
Raising Test In Pediatric Shock –
Preliminary Observations
Priyavarthini V, Suchitra Ranjit,
Sathishkumar K, Rajeshwari Nataraj
PICU, Apollo Children’s Hospital,
Chennai
12/3/2015
1

2. Introduction
• Passive leg raising (PLR) test to
assess fluid responsiveness (FR)
has been validated extensively in
adults
• Pediatric literature – limited to 2
studies
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3. Objective
 To determine if PLR induced changes in
hemodynamic parameters predict FR in
children with shock.
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4. Materials and Methods
• Prospective observational study
• Setting: Pediatric Intensive Care Unit,
Apollo Children’s Hospital
• Study period: August 2013 to October
2014
• No of patients: 26
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5. Criteria
• Inclusion criteria:
– Children with tachycardia with one other sign of
shock
• Exclusion criteria:
– De-compensated shock requiring immediate
fluid resuscitation
– Fracture of lower limbs
– Raised intracranial pressure
– Raised intra abdominal pressure
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6. Materials and Methods
• Hemodynamic variables
were recorded using
Ultrasonic Cardiac Output
Monitor (USCOM)
• Images were obtained by
three trained personnel
with quality assessment of
the images done periodically
by an expert in the use of the
USCOM
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7. • Hemodynamic variables were recorded
– at baseline
– after PLR
– after volume loading (fluid bolus 20 ml/Kg over
30 minutes )
• No other intervention/ drugs were given
during the entire duration of observation
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BASELINE PLR 450 AFTER VOLUME
LOADING

8. PLR manoeuvre
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9. Materials and Methods
• Variables measured and the cut offs * used to
assess response to PLR:
• An increase in Stroke Volume Index more
than 10% after volume loading was
considered a positive response to fluids
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* The role of passive leg raising to predict fluid responsiveness in
pediatric intensive care unit patients. Vimaladewi Lukito et al, Pediatr
Crit Care Med 2012 Vol. 13, No. 3 e155
Parameter Cut off Value
Heart Rate (HR) <5%
Stroke Volume Index
(SVI)
>10%
Cardiac Index (CI) >10%

10. 12/3/2015
Results - Demographics
Mean ± SD (Range) or n (%)
Age (Years) 6.6 ± 5.4 (0.3 to 16)
M/F 16 (61.5%)/10(38.5%)
Weight (kg) 22.2 ± 15.7 (5-54)
Height (cm) 110.3 ±32.4 (59-166)
BSA (m2) 0.81 ± 0.4 (0.29 – 1.52)
Mechanical Ventilation 13 (50%)
Inotropic support 5 (19.2%)
Diagnosis
Sepsis 19 (73.1%)
Hypovolemia 6 (23.1%)
Others 1 (3.8%) 10

11. Results – Age Distribution
0
2
4
6
8
10
12
14
16
18
20
All Responders Non-Responders
19
6
13
7
3
4
<7 >7
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12. Results
9
35%
17
65%
Response to volume loading (SVI >10%)
Fluid responders
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13. Results
Response
to PLR
Response to
fluid challenge
(SVI increase
>10%)
Sensitivi
ty
(%)
Specifici
ty
(%)
PPV NPV
Yes
(n)
No (n)
Increase in
SVI (>10%)
Yes 8 0 88.9 100 100 94.4
No 1 17
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14. 12/3/2015
Results
Response
to PLR
Response to
fluid challenge
(SVI increase
>10%)
Sensitiv
ity
(%)
Specific
ity
(%)
PPV NPV
Yes
(n)
No (n)
Decrease
in HR (>
5%)
Yes 5 1 55.6 94.1 83.3 80
No 4 16
Increase in
CI (>10%)
Yes 5 1 55.6 94.1 83.3 80
No 4 16 14

15. Discussion
• In our study, we included only patients
who had shock - compared to the previous
studies in children
– Lukito et al
– Guo-ping lu et al
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16. Results comparison
Increase in
SV in
response to
PLR
Sensitiv
ity
(%)
Specificit
y
(%)
PPV NPV
Our study
88.9 100 100 94.4
Lukito et al 45 85 75 60
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17. 12/3/2015 17
Response to PLR Sensitivity
(%)
Specificity
(%)
PPV NPV
Increase in CI
Our study 55.6 94.1 83.3 80
Lukito et al 55 85 78 65
Guo-ping lu et al 94 26 49 86
Results comparison

18. Results comparison
Response to PLR Sensitivity
(%)
Specificity
(%)
PPV NPV
Decrease in HR
Our study 55.6 94.1 83.3 80
Lukito et al 35 70 54 52
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19. In essence...
• Our study says..
• If the PLR test is negative then the patient
is less likely to respond to fluids (High
NPV in both clinical & hemodynamic
indices)
• If PLR is positive, in terms of increase in
SVI by more than 10%, there is a high
likelihood of response to fluids
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20. Limitations
• Small sample size
• Variable baseline characteristics
• Less responders to volume challenge
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21. Conclusion
• PLR is highly specific and has a high
Negative Predictive Value
• An increase in SVI by >10% after PLR may
be a better predictor of a response to fluid
challenge in children compared to other
studied variables
• Larger numbers are required to validate these
findings.
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