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Intra-Abdominal Hypertension Is Responsible for False Negatives to the Passive Leg Raising Test

Beurton, Alexandra MD1,2; Teboul, Jean-Louis MD, PhD1,2; Girotto, Valentina MD1; Galarza, Laura MD1; Anguel, Nadia MD1; Richard, Christian MD1; Monnet, Xavier MD, PhD1,2

doi: 10.1097/CCM.0000000000003808
Online Clinical Investigations
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Objectives: To compare the passive leg raising test ability to predict fluid responsiveness in patients with and without intra-abdominal hypertension.

Design: Observational study.

Setting: Medical ICU.

Patients: Mechanically ventilated patients monitored with a PiCCO2 device (Pulsion Medical Systems, Feldkirchen, Germany) in whom fluid expansion was planned, with (intra-abdominal hypertension+) and without (intra-abdominal hypertension–) intra-abdominal hypertension, defined by an intra-abdominal pressure greater than or equal to 12 mm Hg (bladder pressure).

Interventions: We measured the changes in cardiac index during passive leg raising and after volume expansion. The passive leg raising test was defined as positive if it increased cardiac index greater than or equal to 10%. Fluid responsiveness was defined by a fluid-induced increase in cardiac index greater than or equal to 15%.

Measurements and Main Results: We included 60 patients, 30 without intra-abdominal hypertension (15 fluid responders and 15 fluid nonresponders) and 30 with intra-abdominal hypertension (21 fluid responders and nine fluid nonresponders). The intra-abdominal pressure at baseline was 4 ± 3 mm Hg in intra-abdominal hypertension– and 20 ± 6 mm Hg in intra-abdominal hypertension+ patients (p < 0.01). In intra-abdominal hypertension– patients with fluid responsiveness, cardiac index increased by 25% ± 19% during passive leg raising and by 35% ± 14% after volume expansion. The passive leg raising test was positive in 14 patients. The passive leg raising test was negative in all intra-abdominal hypertension– patients without fluid responsiveness. In intra-abdominal hypertension+ patients with fluid responsiveness, cardiac index increased by 10% ± 14% during passive leg raising (p = 0.01 vs intra-abdominal hypertension– patients) and by 32% ± 18% during volume expansion (p = 0.72 vs intra-abdominal hypertension– patients). Among these patients, the passive leg raising test was negative in 15 patients (false negatives) and positive in six patients (true positives). Among the nine intra-abdominal hypertension+ patients without fluid responsiveness, the passive leg raising test was negative in all but one patient. The area under the receiver operating characteristic curve of the passive leg raising test for detecting fluid responsiveness was 0.98 ± 0.02 (p < 0.001 vs 0.5) in intra-abdominal hypertension– patients and 0.60 ± 0.11 in intra-abdominal hypertension+ patients (p = 0.37 vs 0.5).

Conclusions: Intra-abdominal hypertension is responsible for some false negatives to the passive leg raising test.

1Service de médecine intensive-réanimation, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, Assistance publique – Hôpitaux de Paris, Le Kremlin-Bicêtre, France.

2Inserm UMR S_999, Université Paris-Sud, Le Kremlin-Bicêtre, France.

Dr. Beurton collected the data, performed data analysis, and drafted the article. Dr. Teboul conceived the study and supervised data analysis and article writing. Drs. Girotto, Galarza, and Anguel contributed to data recording. Dr. Richard supervised the study. Dr. Monnet conceived the study, supervised data analysis and article writing, and coordinated the study. All authors approved the final version of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Dr. Teboul received funding from Pulsion/Getinge. Dr. Monnet has given some lectures for Cheetah Medical. Drs. Teboul and Monnet are members of the Medical Advisory Board of Pulsion Medical Systems. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: alexandra.beurton@aphp.fr

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