Passive Leg Raising

Pendahuluan
• 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
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)
Prefomance Characteristic
• 9% increase in stroke volume has 86% sensitivity and 90% specificity
• 10% increase in pulse pressure has 79% sensitivity and 85% specificity
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
Disandvantages
• unreliable in severely hypovolemic 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
• 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
PEEP
• Positif End Expiratory Pressure
• Merupakan metode ventilasi saat pernafasan dijaga diatas tekanan
atmosfir pada akhir ekspirasi nafas.
• Tujuannya adalah untuk meningkaatkan volume gas yang tersisa di
paru-paru pada akhir ekspirasi
• Nilai PEEP dimulai dari 5 cmH20 sampai 20 cmH20
• PEEP meningkatkan FRC
• Dengan PEEP konsentrasi oksigen inspirasi diturunkan sehingga dapat
mengurangi toksisitas oksigen.
• Peningkatan KRF akan meningkatka jumlah unit respirasi yang
mendapatkan udara sepanjang siklus respirasi, meningkatkan
keseimbangan V/Q dan oksigenasi
• Paru dengan konsolidasi cenderung kolaps. Peningkatan KRF akan
merekrut sejumlah segmen untuk ikut aktif dalam ventilasi, sehingga
memperbaiki oksigenasi.
• Pada pasien dengan edema paru, peningkatan volume paru yang
mendapatkan aliran udara akan meningkatkan kapasitas intersisial
paru terhadap cairan sehingga mengurangi edema alveolar.
• Pada pasien dengan paru yang kaku dan sulit mengembang,
peningkatan KRF akan menggeser paru ke titik yang lebih baik pada
kurva tekanan/volume, sehingga sedikit usaha nafas subjek sudah
cukup untuk mengembangkan paru saat inspirasi.