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Cheetah Medical
www.cheetahnicom.com

PASSIVE LEG RAISE (PLR) TEST

Estimation of Fluid Responsiveness

First Step Baseline

45°

Patient position: Lying in a semi-recumbent

position

StroOkbtaein V reoadlinugsm (eqeua lsI nto d

3 3

m einxut e(s)SVI)

Second Step Challenge

30°-45°

30 45
Patient position: Passive leg raise (about -  degrees)
Obtain 3 readings (equals to 3 minutes). In fluid
responsive* patients look for the following anticipated stroke volume
index response:

SVI )  10  %
Fluid Responsive: SVI will increase by >15% in response to
*
500 mL IV fluid
administration

Test is positive: SVI rise )  10% ; Patient is Fluid Responsive

Test is negative: SVI rise < 10% ; Patient is not Fluid Responsive

See references on back
NICOM Sensors should be replaced with a new set of sensors after 488 hours of use.
Remember to perform a re- calibration after sensor replacement and once daily.
 REFERENCES
1. Benhomar B, Outattara A, Brusset A, et al. Use of transthoracic Bioreactance during
passive leg raise test to determine fluid Responsiveness. European Society of Intensive
Care Medicine, 2009
“Bioreactance-based CO assessment is a sensitive and speci fic method for assessing fluid
responsiveness. The high precision and responsiveness of this tool enable using a low
threshold of 5% PLR response, in a quick time frame of 3 min. following PLR. The sensitivity
and specificity to predict a 10% increase in CO following  500 mL bolus infusion are 93% and
71%, respectively”.
Meaning: Bioreactance in conjunction with a PLR is highly sensitive and specific to
detect fluid responsiveness. The technology is responsive and precise enough to
provide a directional reading after just minutes of challenge.
2. Lamia B, Cuvelier A, Declercq PL, et al. Response of NICOM stroke volume to passive
leg raising to predict fluid responsiveness in critically ill patients with spontaneous
breathing activity. International Symposium on Intensive Care and Emergency
Medicine, 2010
“…Our objective was to test whether volume responsiveness could be predicted by the
response of stroke volume measured by the NCOM device to passive leg raising (PLR) in
patients with spontaneous breathing activity. Methods: Prospective study in the respiratory
critical care of a university hospital. Patients: 11 patients with spontaneously breathing
activity considered for volume expansion. An increase in stroke volume index (SVi) of
15% or more after volume expansion de fined a responder patient. We measured the
response of the Bioreactance stroke volume to passive leg raising and to saline infusion
(500 ml over 15 min). Results: The proportional changes in NiCOM-SVi induced by PLR were
correlated with the proportional changes in NICOM-SVi induced by volume expansion (r=
0.67, p= 0.02). The proportional changes in NICOM-cardiac index (CI) induced by PLR were
also correlated with the proportional changes in NICOM-CI induced by volume expansion
(r= 0.63, p= 0.03). A passive leg raising induced increase in stroke volume of 9% or more
predicted an increase in stroke volume of 15% or more after volume expansion with a
sensitivity of 100% and a specificity of 80%. Conclusions: The response of NICOM-stroke
volume to passive leg raising was a good predictor of volume responsiveness. In our
hemodynamically unstable patients
with spontaneous breathing activity, fluid responsiveness can be assessed totally non-invasively
with a bioreactance device.”
Meaning: As in Benhomar et al.
3. Cavallaro F, Sandroni C, Marano C, et al. Diagnostic accuracy of passive leg raising
for prediction of fluid responsiveness in adults: systematic review and meta-
analysis of clinical studies. Intensive Care Med. 2010;36(9):1475-1483
“Passive leg raising-induced changes in cardiac output reliably predict fluid responsiveness
regardless of ventilation mode, underlying cardiac rhythm and technique of measurement
and can be recommended for routine assessment of fluid responsiveness in the majority of
ICU population.”
Meaning: Speaks for itself.
4. Maizel J, Airapetian N, Lorne E, et al. Diagnosis of central hypovolemia by using passive
leg raising. Intensive Care Med 2007; 33: 1133– 1138
"This prospective study was performed in four intensive care units… This study shows that
changes in CO or SV during PLR (passive leg raise) are predictive of central hypovolemia….
An increase by more than 12% of cardiac output or SV during PLR was predictive of a
positive hemodynamic response after fluid expansion…. In spontaneously breathing
patients with suspected hypovolemia, cardiac output or stroke volume measurement using
echocardiography during passive leg raising can very accurately discriminate patients who
will obtain a hemodynamic benefit from fluid challenge.”
Meaning: In ICU patients a positive PLR test done by echo helps guide fluid
management. Potential implication: While echo is intermittent, expensive and requires
a high skilled clinician to perform, a NICOM PLR can be performed by the nurse quickly
and in cost-effective fashion on a large volume of patients.
5. Lamia B, Ochagavia A, Monnet X, et al. Echocardiographic prediction of volume
responsiveness in critically ill patients with spontaneously breathing activity. Care Med
2007; 33:1125–1132
“A passive leg raising induced increase in stroke volume of 12.5% or more predicted an
increase in stroke volume of 15% or more after volume expansion with a sensitivity of
77% and a specificity of 100%. Neither left ventricular end-diastolic area nor the ratio of
mitral inflow wave velocity to early diastolic mitral annulus velocity predicted volume
responsiveness. In our critically ill patients with spontaneous breathing activity the response of
echocardiographic stroke volume to passive leg raising was a good predictor of volume
responsiveness. On the other hand, the common echocardiographic markers of cardiac
filling status were not valuable for this purpose”.
Meaning: As in Maizel, et al.
6. Marik PE, Baram M, Vahid B, et al. Does Central Venous Pressure Predict Fluid
Responsiveness? A Systematic Review of the Literature and the Tale of Seven Mares.
Chest 2008; 134:172–178
“A systematic review of the literature to determine: (1) relationship between CVP and blood
volume, (2) ability of CVP to predict fluid responsiveness, and (3) ability of the change in
CVP ([CVP) to predict fluid responsiveness The pooled correlation coefficient between
baseline CVP and change in stroke index/cardiac index was 0.18 (95% CI, 0.08 to 0.28).
The pooled correlation between [CVP and change in stroke index/cardiac index was
0.11 (95% CI, 0.015 to 0.21). Baseline CVP was 8.7 ± 2.32 mm Hg [mean ± SD] in the
responders as compared to 9.7 ± 2.2 mm Hg in nonresponders (not significant). This
systematic review demonstrated a very poor relationship between CVP and blood
volume as well as the inability of CVP/[CVP
to predict the hemodynamic response to a fluid challenge. CVP should not be used to make
clinical decisions regarding fluid management.”
Meaning: Measurements of venous pressures (CVP) should not be used to make decisions
on fluid management.
7.
Monnet X, Teboul JL. Passive leg raising. Intensive Care Med 2008; 34:659-63
"Predicting fluid responsiveness solely on the basis of measures of preload must be discouraged.
In this regard cardiac filling pressures such as central venous pressure and pulmonary artery
occlusion pressure cannot differentiate between patients responding and patients not
responding to fluid administration. Fluid responsiveness assessment must be rather based on
the response to dynamic tests which induce transient changes in cardiac preload. The
physiological effects of PLR consist of an increase in venous return and cardiac preload. The
PLR thus acts as a self-volume challenge which is easy to-perform and completely
reversible. It has gained an increasing interest in the field of functional hemodynamic
monitoring. PLR test should be increasingly used at the bedside since it is easy to perform
and effective, provided that its effects are assessed by a real-time measurement of cardiac
output. The optimal use of PLR requires a real-time cardiovascular assessment device able to
quantify accurately the short-term hemodynamic response.”
Meaning: Speaks for itself.
8. Préau S, Saulnier F, Dewavrin F, et al. Passive leg raising is predictive of fluid responsiveness
in spontaneously breathing patients with severe sepsis or acute pancreatitis. Crit Care
Med. 2010;38(3):819-25
"Rapid fluid loading is standard treatment for hypovolemia. Because volume expansion does
not always improve hemodynamic status, predictive parameters of fluid responsiveness are
needed... Passive leg raising-induced changes in stroke volume and its surrogates are
reliable predictive indices of volume expansion responsiveness for mechanically ventilated
patients. We hypothesized that the hemodynamic response to passive leg raising indicates
fluid responsiveness in nonintubated patients without mechanical ventilation... Patients: 
We investigated consecutive nonintubated patients, without mechanical ventilation,
considered for volume expansion. Interventions: We assessed hemodynamic status at
baseline, after passive leg raising, and after volume expansion (500 mL 6% hydroxyethyl
starch infusion over 30 mins). Results: ...All patients included in the study had severe sepsis
(n = 28; 82%) or acute pancreatitis (n = 6; 18%). The Deltastroke volume >or=10% predicted
fluid responsiveness with sensitivity of 86% and specificity of 90%. The Deltapulse pressure
>or=9% predicted fluid responsiveness with sensitivity of 79% and specificity of 85%. The
Deltavelocity of femoral artery flow >or=8%  predicted fluid responsiveness with sensitivity
of 86% and specificity of 80%. Conclusions: Changes in stroke volume... induced by passive
leg raising are accurate and interchangeable indices for predicting fluid responsiveness in
nonintubated patients with severe sepsis or acute pancreatitis.”
Meaning: Measurement of the Stroke Volume response to PLR is highly sensitive and
specific in spontaneously breathing patients suffering from severe sepsis and acute
pancreatitis.
9. Marik P, Monnet X, Teboul JL. Hemodynamic parameters to guide fluid therapy. Ann
Intensive Care, 2011;1:1 
"It should be appreciated that both arrhythmias and spontaneous breathing activity will
lead to misinterpretations of the respiratory variations in pulse pressure/ stroke volume.
Furthermore, for any specific preload condition the PPV/SVV will vary according to the tidal
volume… The change in aortic blood flow (measured by esophageal Doppler) during a 45°
leg elevation was shown to predict the changes in aortic blood flow produced by a 500-mL
fluid challenge even in patients with cardiac arrhythmias and/or spontaneous ventilator
triggering, situations in which PPV lost its predictive ability. A recent meta-analysis, which
pooled the results of eight recent studies, confirmed the excellent value of PLR to predict
fluid responsiveness in critically ill patients with a global area under the receiver operating
characteristic curve of 0.95… In the initial stages of resuscitation in the emergency room,
ward, or ICU, most patients are not intubated and are breathing spontaneously. In addition,
with the reduced use of sedative agents in the ICU, many critically ill patients are ventilated
with modes of ventilation that allow spontaneous breathing activity. Because the
respiratory variability of hemodynamic signals cannot be used for predicting volume
responsiveness in spontaneously breathing patients, other techniques, such as passive leg
raising (PLR), have been proposed for this purpose… The cardiac output as measured by
bioreactance has been shown to be highly correlated with that measured by thermodilution
and pulse contour analysis. In a cohort of patients after elective cardiac surgery, Benomar
and coauthors demonstrated that the NICOM™ system could accurately predict fluid
responsiveness from changes in cardiac output during PLR. The NICOM™ system has an
algorithm with user prompts and an interface that rapidly facilitates the performance of a
PLR maneuver. Although the dynamic changes of the plethysmographic waveform have been
demonstrated to be predictive of volume responsiveness in ventilated patients, this
technology is poorly predictive of volume responsiveness in spontaneously breathing
persons after a PLR challenge. The hemodynamic effects of PLR must be assessed by a
direct measure of cardiac output or stroke volume; assessing the PLR effects solely on the
arterial pulse pressure leads to a significant number of false-negative cases. This suggests
that in spontaneously breathing patients, pulse pressure is not of sufficient sensitivity for
detecting changes in stroke volume.”
Meaning: SVV and PVV are innacurate in situtations of spontaneous breathing, ventilation
to a tidal volume of less than 8- 1 mL/kg, and in patients with cardiac arrhythmias. In
contrast, measuring SV in context of a PLR retains accuracy in these situations.
Bioreactance has been shown to be highly accurate in. 
Code: M-PLR Rev. 07 August 13, 2012