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The Effect of Passive Leg Raising Towards Hemodynamics on Patient with Hypovolemic Shock at the Emergency Ward of Dustira Cimahi Hospital

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The Effect of Passive Leg Raising Towards Hemodynamics on Patient with Hypovolemic Shock at the Emergency Ward of Dustira Cimahi Hospital International Seminar on Global Health (ISGH) 2017 Stikes Jenderal Achmad Yani Cimahi The Effect of Passive Leg Raising towards Hemodynamics on Patient with Hypovolemic Shock at the Emergency Ward of Dustira Cimahi Hospital Evangeline Hutabarat Nursing Science Dept., Stikes Jenderal Achmad Yani Cimahi Email: [email protected] Abstract One of the conditions needing immediate response in the emergency ward is hypovolemic shock. The patient in shock requires close monitoring for clinical signs and hemodynamic status and intravascular status. It is due to circulatory assistance and medication provision on the patient is given based on the accuracy of the intravascular volume status of the patient. Fluid responsiveness can be considered as basis for considering administering fluid only or inotropic and vasopressor medication for the patient to maintain her circulatory homeostatic. Passive Leg Raising (PLR) may be a reversible method to evaluate fluid responsiveness. The study aims at evaluating the effect of PLR on hemodynamic. It employs the quasi-experimental design with the within subject repeated measurement design approach. 48 respondents took part as samples, with the consecutive sampling method implemented. The samples were then categorized into responsive and non-responsive groups based on the increase of pulse pressure amounting to or beyond 9% during PLR implementation. The data was tested using the dependent and independent t test to provide analysis for uni-variate and bivariate data. The results indicated that 34 respondents belonged to the responsive group while 14 respondents were categorized as non-responsive. There was a significant relationship between PLR and hemodynamic parameters of systolic blood pressure, diastolic blood pressure, mean arterial pressure, and pulse pressure (p>0.05). It implied that PLR may be used as an evaluation method for fluid responsiveness on patients with hypovolemic shock. Key words: hemodynamic, hypovolemic shock, passive leg raising Introduction One of the conditions that requires immediate action in Emergency Ward is shock. It is an emergency that needs aggressive therapy and continuous monitoring of blood circulation. (Aaronson& Ward, 2010, Jevon & Ewens, 2009). Circulation assistance is generally conducted by fluid resuscitation. Among the types of shock, hypovolemic shock with various ehtiology shows a high prevalence in the Emergency Ward. A study conducted by Levy et al (2004) and Otero et al (2006) concluded that early and accurate administration on hypovolemic shock can reverse a hypoxia state as well as prevent organ failure. On the contrary, excessive fluid resuscitation for shock causes fatal lung edema and gas exchange. Literary studies show that excessive fluid provision relates to incidents of complications among emergency ward patient, sustain LOS and increases mortality (Rosenberg, 2009; Murphy, 2009; Boyd, 2010). The ability of a nurse in the emergency ward in identifying the intravascular volume status of an emergency ward patient is crucial and fundamental (Singh & Lighthall, 2011). Fluid responsiveness can be interpreted as the ability of a patient to maintain her homeostasis circulation through only fluid provision or inotropic as well as vasopressor. In reality, fluid resuscitation does not always improve hemodynamic (Frederic, 2002). Passive Leg Raising (PLR) may be a reversible method to judge whether it is beneficial for the patient. During PLR administration, to the extremity of 45o elevation, approximately 500 cc of blood from such lower extremities will flow to an intra thoracic compartment area and increases the left and right ventricle preloads and consequently affects the ventricular stroke volume (SV) towards CO (Monet, 2008). Literature Review 271 International Seminar on Global Health (ISGH) 2017 Stikes Jenderal Achmad Yani Cimahi Hypovolemic shock treatment can be done through intravenous fluid administration and if needed inotropic medication to maintaining cardiac functions or vasoconstrictor medication to handle peripheral vasodilatation. It also ceases visible hemorrhage and acute pain immediately which may be the causes of shock. Circulation assistance given is based on the accuracy of the intervascular volume status and fluid responsiveness. A method to evaluate fluid responsiveness is Passive Leg Raising where both legs are elevated and the fluids or blood from such extremity flows to the central circulation to raise SV and CO followed by hemodynamic changes. If PLR is able to raise pulse pressure at least 9% the patient is considered responsive and will benefit from fluid provision (Levitov, 2011, Summers, 2010 (Lamia, 2007, Caile, 2008). Hemodynamic monitoring is the center of critical and emergency patient nursing. In a research from Badin, Boulain ans Ehrman (2011) MAP is a predictor of acute kidney injury (AKI). It was found that patients experiencing shock and having below normal MAP (< 65mmHg) in the first 24 hours runs the risk of experiencing AKI in the next 72 hours. Besides MAP, changes in pulse pressure (PP) or the difference between SBP and DBP is more accurate to detect shock than SBP where the normal pressure is approximately 30-40 mmHg. In hypovolemic shock, a significant decline in SV and PP can occur before a notable drop in SBP. PP is determined by SV (the amount of fluid ejected in every cardiac contraction) compliance arterial system and ejection characteristics during diastole. PP remarkably reflects SV (Aaronson & Ward, 2010). Passive Leg Raising (PLR) or more commonly referred to as the shock position is carried out by emergency nurses at the pre-hospital or hospital phase on shock patients to sustain maximum blood flow to vital organs. Passive Leg Raising has another important use which is to predict whether a patient will benefit from fluid resuscitation administration. When PLR is performed with a 45o elevation, blood from lower vein extremity flows to intrathoracic compartment area and raises right and left ventricle preload and affects the volume of contracted ventricle and heart flow (Monet, 2008). Method The study is a quasi-experiment research deploying the Within Subject Repeated Measurement design. The population comprises of patients with hypovolemic shock at the Emergency Ward of Dustira Cimahi Hospital in the duration of the research period. The sampling technique was that of consecutive sampling which every criteria qualifying patient was included until the number needed was met. It also deployed the coupled numeric-analytic research type implementing errors of type I at 1.65 and type II at 0.84, a combined standard deviation of 6.4 and a significant minimum difference of 4.8 thus the population of 24 patients. The independent variable was Passive Leg Raising (PLR). PLR is a method to predict whether a patient requires fluid resuscitation: when legs are raised at a 45o angle fluids from lower limbs flow to the central circulation and increases the stroke volume whose effects is visible from the changes of the hemodynamic parameters (Preau, et al, 2010; Jabot, Teboul, Monynet & Richard, 2009). The dependent variables were the hemodynamic parameters, namely MAP (mean arterial pressure) and PP (pulse pressure). The research was conducted by implementing Passive Leg Raising (PLR) which was elevating both lower extremities of a respondent using two pillows for two minutes. Before observation, the degree between the legs were raised and the bed was measured with a goniometer bearing 45˚ followed by liquid intravenous administration of NaCl 0.9% as much as 500 cc (loading), compliant to the local protocols of shock patient treatment at the Emergency Ward of Dustira Hospital where the research was conducted. Results and Discussion Most respondents belong to the mid-adult age group category (62%). Based on gender, most respondents are male (37,5%). Most respondents are categorized into the responsive group (71%) and all respondents were given a diagnosis of acute gastroenteritis. The following table represents the hemodynamic averages in every stage of observation/data accumulation based on the responsive and non-responsive group categories. 272 International Seminar on Global Health (ISGH) 2017 Stikes Jenderal Achmad Yani Cimahi Table 1 The Averages of Hemodynamic Based on Observation Stages and the Responsive and Non-responsive Groups. B1 Variabel PLR B2 IV Mean ± SD Mean ± SD Mean ± SD Mean ± SD MAP Responsif 76.41 ± 6 81.53 ± 5.9 80 ±5.7 83 ± 5.7 Non-responsif 76 ± 6.5 70 ± 4.42 76 ± 4.3 79 ± 7.6 PP Responsif 26.76 ± 5.0 28.2 ± 5 26.8 ± 4.9 29. 8 ± 5.23 Non-responsif 26.71± 3.55 28.0 ± 2.7 26.9 ± 2.6 28.14 ± 2.5 Note: B1 (baseline 1) = before PLR, B2 (baseline 2) = after PLR/before fluid IV administration, IV = after fluid IV administration. The results of the responsive group data analysis show that there is significant difference between MAP and PP. In the responsive group, there is proof that PLR causes an increase in hemodynamic. When PLR is implemented with extremities elevated at 45o, blood from lower extremity veins as much as 500 cc to the intrathoracic compartment area (Monet, 2008). Lafanechere et al in their research (2006) concludes that PLR can predict fluid responsiveness in respondents who experience acute circulation failure (Levitov, 2011; Summers, 2010; Lamia, 2007; Caile, 2008; Benomar, 2010). The abovementioned researches take roots in a simple physiological logic that PLR facilitates RFL (rapid fluid loading) and raises venous return, stroke volume and cardiac output which
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