OVERVIEW

 Passive Leg Raise (PLR) transiently increases venous return in

patients who are preload responsive, as such it is a diagnostic
test not a treatment
 it is a predictor of Fluid responsiveness (i.e. helps identify
patients who are on the ascending portion of their Starling Curve,
and will have an increase in stroke volume in response to fluid
administration)

TECHNIQUE

 sit patient at 45 degrees head up semi-recumbent position

 lower patient’s upper body to horizontal and passively raise legs
at 45 degrees up
 maximal effect occurs at 30-90 seconds
 assess for a 10% increase in stroke volume (cardiac output
monitor) or using a surrogate such as pulse pressure (using an
arterial line)

PERFORMANCE CHARACTERISTICS

 9% increase in stroke volume has 86% sensitivity and

90% specificity
 10% increase in pulse pressure has 79% sensitivity and
85% specificity
 A small yet-to-be-validated study found that a PLR-induced
increase in EtCO(2) ≥ 5 % predicted a fluid-induced increase in
 CI ≥ 15 % with 71% sensitivity (95 %CI = 48-89 %) and
100% specificity (95%CI = 82-100%)

PROS AND CONS

Advantages

 reversible
 non-invasive
 easy to perform in patients breathing spontaneously and with
arrhythmias (but must use measures other than stroke volume
variation and pulse pressure variation)
 can be repeated many times to reassess preload
responsiveness without any risk of inducing pulmonary edema or
cor pulmonale in potential nonresponders

Disadvantages

 unreliable in severely hypovolemic patients

— the blood volume mobilized by leg-raising (which is dependent
on total blood volume) could be small and can show minimal to
no increase in CO and blood pressure, even in fluid responsive
patients
 need to stop any other interventions during the test
 positional changes may be contra-indicated in some patients
 not useful in patients with raised intra-abdominal pressure
References and Links

LITFL
  CCC — Fluid challenge
 CCC — Fluid responsiveness
 CCC — Systolic Pressure Variation

Journal articles

 Monnet X, Bataille A, Magalhaes E, Barrois J, Le Corre M,

Gosset C, Guerin L, Richard C, Teboul JL. End-tidal
carbon dioxide is better than arterial pressure for predicting
volume responsiveness by the passive leg raising test.
Intensive Care Med. 2013 Jan;39(1):93-100. doi:
10.1007/s00134-012-2693-y. Epub 2012 Sep 19. PubMed
PMID: 22990869.
 Monnet X, Bleibtreu A, Ferré A, Dres M, Gharbi R, Richard
C, Teboul JL. Passive leg-raising and end-expiratory
occlusion tests perform better than pulse pressure variation
in patients with low respiratory system compliance. Crit
Care Med. 2012 Jan;40(1):152-7. doi:
10.1097/CCM.0b013e31822f08d7. PubMed
PMID: 21926581.
 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
May;34(5):1402-7. PubMed PMID:16540963.
 Préau S, Saulnier F, Dewavrin F, Durocher A, Chagnon JL.
Passive leg raising is predictive of fluid responsiveness in
spontaneously breathing patients with severe sepsis or
acute pancreatitis. Crit Care Med. 2010 Mar;38(3):819-25.
doi: 10.1097/CCM.0b013e3181c8fe7a. PubMed
PMID: 20016380.