Assessing Passive Leg Raise Test in Pediatric Shock Using Electrical Cardiometry

Abstract

Passive leg raise (PLR) is widely used to incite an autobolus to assess fluid responsiveness in adults; however, there is a paucity of studies exploring its utility in children. Our study aimed to analyze the efficacy of PLR in determining fluid responsiveness in children presenting with shock using electrical cardiometry. Patients in the age group of 0 to 20 years who presented in shock to our children's hospital emergency department were evaluated. Multiple hemodynamic metrics including, heart rate, systolic/diastolic blood pressure, cardiac output (CO), stroke index, stroke volume (SV), flow time corrected (FTC), and left ventricular ejection time (LVET) were recorded using the noninvasive ICON device and compared at baseline and post-PLR. A total of 68 patients had pre- and post-PLR data available for review between June and July 2022. Median age was 7 years (54% male); most common etiology was hypovolemic (67.6%) shock. Following PLR, there was no significant change in most hemodynamic parameters, including SV and CO; however, there was a significant difference in FTC (301 [pre-PLR] vs. 307 [post-PLR], p = 0.016) (ms) and LVET (232 [pre-PLR] vs. 234 [post-PLR], p = 0.014) (ms). A significantly higher proportion of children diagnosed with septic shock demonstrated fluid responsiveness (ΔSV ≥ 10% from baseline) compared with those with hypovolemic shock (p = 0.036). This study demonstrated no identifiable fluid responsiveness (ΔSV ≥ 10% from baseline) following PLR; however, a significantly higher proportion of children suffering from septic shock demonstrated fluid responsiveness compared with those with hypovolemic shock. Larger studies are needed to further assess the utility of PLR, as well as other modalities, in determining fluid responsiveness in children.

Keywords

passive leg raise - fluid responsiveness - hemodynamic monitoring - NICOM - emergency department

Previous Presentation

The abstract was presented as a podium presentation at the 2023 Critical Care Congress: Annual Meeting in San Francisco, CA (January 21–24, 2023).

^* Dr. Bhalala was affiliated with Driscoll Children's Hospital & Texas A & M University during study period and now affiliated with Amistad Health.

Publication History

Received: 17 June 2023

Accepted: 20 November 2023

Article published online:
26 December 2023

• References

• 1 Mendelson J. Emergency department management of pediatric shock. Emerg Med Clin North Am 2018; 36 (02) 427-440
• 2 Festekjian A, Glavinic J. Pediatric septic shock: recognition and management in the emergency department. Pediatr Emerg Med Pract 2022; 19 (11) 1-24
• 3 Weiss SL, Peters MJ, Alhazzani W. et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Pediatr Crit Care Med 2020; 21 (02) e52-e106
• 4 Singh Y, Villaescusa JU, da Cruz EM. et al. Recommendations for hemodynamic monitoring for critically ill children-expert consensus statement issued by the cardiovascular dynamics section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Crit Care 2020; 24 (01) 620
• 5 Leisman D, Wie B, Doerfler M. et al. Association of fluid resuscitation initiation within 30 minutes of severe sepsis and septic shock recognition with reduced mortality and length of stay. Ann Emerg Med 2016; 68 (03) 298-311
• 6 Lee SJ, Ramar K, Park JG, Gajic O, Li G, Kashyap R. Increased fluid administration in the first three hours of sepsis resuscitation is associated with reduced mortality: a retrospective cohort study. Chest 2014; 146 (04) 908-915
• 7 Santillanes G, Rose E. Evaluation and management of dehydration in children. Emerg Med Clin North Am 2018; 36 (02) 259-273
• 8 Oliveira CF, Nogueira de Sá FR, Oliveira DS. et al. Time- and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to the implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a pediatric intensive care unit in a developing world. Pediatr Emerg Care 2008; 24 (12) 810-815
• 9 Sutherland SM, Zappitelli M, Alexander SR. et al. Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis 2010; 55 (02) 316-325
• 10 El-Nawawy A, Moustafa AA, Antonios MAM, Atta MM. Clinical outcomes associated with fluid overload in critically ill pediatric patients. J Trop Pediatr 2020; 66 (02) 152-162
• 11 Raina R, Sethi SK, Wadhwani N, Vemuganti M, Krishnappa V, Bansal SB. Fluid overload in critically ill children. Front Pediatr 2018; 6: 306
• 12 Alobaidi R, Morgan C, Basu RK. et al. Association between fluid balance and outcomes in critically ill children: a systematic review and meta-analysis. JAMA Pediatr 2018; 172 (03) 257-268
• 13 Davis AL, Carcillo JA, Aneja RK. et al. American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Crit Care Med 2017; 45 (06) 1061-1093
• 14 Toscani L, Aya HD, Antonakaki D. et al. What is the impact of the fluid challenge technique on diagnosis of fluid responsiveness? A systematic review and meta-analysis. Crit Care 2017; 21 (01) 207
• 15 Gan H, Cannesson M, Chandler JR, Ansermino JM. Predicting fluid responsiveness in children: a systematic review. Anesth Analg 2013; 117 (06) 1380-1392
• 16 Awadhare P, Patel R, McCallin T. et al. Non-invasive cardiac output monitoring and assessment of fluid responsiveness in children with shock in the emergency department. Front Pediatr 2022; 10: 857106
• 17 Assadi F. Passive leg raising: simple and reliable technique to prevent fluid overload in critically ill patients. Int J Prev Med 2017; 8: 48
• 18 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 (09) 1475-1483
• 19 Monnet X, Rienzo M, Osman D. et al. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med 2006; 34 (05) 1402-1407
• 20 Douglas IS, Alapat PM, Corl KA. et al. Fluid response evaluation in sepsis hypotension and shock: a randomized clinical trial. Chest 2020; 158 (04) 1431-1445
• 21 Zakariás D, Marics G, Kovács K. et al. [Clinical application of the electric cardiometry based non-invasive ICON® hemodynamic monitor]. Orv Hetil 2018; 159 (44) 1775-1781
• 22 Coté CJ, Sui J, Anderson TA. et al. Continuous noninvasive cardiac output in children: is this the next generation of operating room monitors? Initial experience in 402 pediatric patients. Paediatr Anaesth 2015; 25 (02) 150-159
• 23 Suehiro K, Joosten A, Murphy LS. et al. Accuracy and precision of minimally-invasive cardiac output monitoring in children: a systematic review and meta-analysis. J Clin Monit Comput 2016; 30 (05) 603-620
• 24 Norozi K, Beck C, Osthaus WA, Wille I, Wessel A, Bertram H. Electrical velocimetry for measuring cardiac output in children with congenital heart disease. Br J Anaesth 2008; 100 (01) 88-94
• 25 Xu SH, Zhang J, Zhang Y, Zhang P, Cheng GQ. Non-invasive cardiac output measurement by electrical cardiometry and M-mode echocardiography in the neonate: a prospective observational study of 136 neonatal infants. Transl Pediatr 2021; 10 (07) 1757-1764
• 26 Kuster M, Haltmeier T, Exadaktylos A, Schnüriger B. Non-invasive cardiac output monitoring device “ICON” in trauma patients: a feasibility study. Eur J Trauma Emerg Surg 2019; 45 (06) 1069-1076
• 27 Mansfield RC, Kaza N, Charalambous A, Milne AC, Sathiyamurthy S, Banerjee J. Cardiac output measurement in neonates and children using noninvasive electrical bioimpedance compared with standard methods: a systematic review and meta-analysis. Crit Care Med 2022; 50 (01) 126-137
• 28 Lee JH, Kim EH, Jang YE, Kim HS, Kim JT. Fluid responsiveness in the pediatric population. Korean J Anesthesiol 2019; 72 (05) 429-440
• 29 Loomba RS, Villarreal EG, Farias JS, Flores S, Bronicki RA. Fluid bolus administration in children, who responds and how? A systematic review and meta-analysis. Paediatr Anaesth 2022; 32 (09) 993-999
• 30 Lu GP, Yan G, Chen Y, Lu ZJ, Zhang LE, Kissoon N. The passive leg raise test to predict fluid responsiveness in children—preliminary observations. Indian J Pediatr 2015; 82 (01) 5-12
• 31 Lukito V, Djer MM, Pudjiadi AH, Munasir Z. The role of passive leg raising to predict fluid responsiveness in pediatric intensive care unit patients. Pediatr Crit Care Med 2012; 13 (03) e155-e160
• 32 El-Nawawy AA, Farghaly PM, Hassouna HM. Accuracy of passive leg raising test in prediction of fluid responsiveness in children. Indian J Crit Care Med 2020; 24 (05) 344-349
• 33 Luo D, Dai W, Lei L, Cai X. The clinical value of passive leg raising plus ultrasound to predict fluid responsiveness in children after cardiac surgery. BMC Pediatr 2021; 21 (01) 243