Continuous Cardiac Output and Near-Infrared Spectroscopy Monitoring to Assist in Management of Symptomatic Cerebral Vasospasm After Subarachnoid Hemorrhage

Background and Purpose-Systemic circulation management has not been established for patients with poor grade aneurysmal subarachnoid hemorrhage (SAH) or delayed cerebral ischemia (DCI) after SAH. The aims of the study were to examine hemodynamic variables in these patients and to establish treatment strategies. Methods-A multicenter prospective cohort study of hemodynamic variables from days 1 to 14 was performed using a transpulmonary thermodilution system (PiCCO Plus

Section: Discussionmentioning

confidence: 96%

Multicenter Prospective Cohort Study on Volume Management After Subarachnoid Hemorrhage

Yanagawa

Nakamura

Shirao

et al. 2013

“…37,38 In patients with a new focal neurological deficit, NIRS detected decreased cerebral oxygenation in the affected region and a rise in oxygenation after treatment with an inotrope. 39,40 However, others have found no such correlation. 41,42 Brain Tissue Oximetry Partial pressure of brain tissue oxygen (PbtO 2 ) is a complex physiological variable that likely reflects the interaction among oxygen delivery, extraction, and tissue demands.…”

Section: Jugular Bulb Oximetrymentioning

confidence: 98%

Multimodal Monitoring in Subarachnoid Hemorrhage

Sandsmark

Kumar

Park

et al. 2012

In severely injured patients, the immediate goal of resuscitation is restoration and maintenance of adequate tissue metabolism by ensuring sufficient delivery of fuel, typically oxygen and glucose, to meet cellular metabolic demands. In neurocritical care, traditional goals of resuscitation-intracranial pressure (ICP), cerebral perfusion pressure (CPP), and the clinical examination-have been extrapolated from those of general critical care. These variables are analogous to central venous pressure, mean arterial pressure, and urine output and are similarly crude. These distant surrogates for cerebral perfusion do not account for dynamic changes in cerebral autoregulation, tissue metabolic rate, cellular fuel use, and microcirculatory dysfunction, all of which impact tissue metabolic health. Although standard, it seems intuitively obvious that a uniform approach of maintaining ICP Ͻ20 mm Hg and CPP Ͼ60 mm Hg is overly simplistic. This approach does not address either significant baseline differences in patient physiology nor the complex, dynamic, and variable pathophysiological changes that ensue after severe brain injury. A more tailored therapeutic strategy that responds to multiple simultaneously measured and more relevant physiological variables is logically appealing. Until recently, however, the requisite individual patient physiology was inaccessible at the bedside.The emergence of technology that allows for continuous real-time bedside monitoring of cerebral physiology marks a new era in neurocritical care. These monitors facilitate assessment of therapeutic efficacy and may provide more relevant physiological end points for resuscitation. Combining these monitors in a multimodal approach allows for the practice of goal-directed cerebral resuscitation that emphasizes the individual patient's unique neurological and systemic physiology.

“…34,35 In the control group, intravenous fluid administration was adjusted according to the fluid balance, calculated every 8 hours by subtracting the urinary volume from the total oral and intravenous fluid volume, to achieve a positive fluid balance of 750 to 1500 mL ( Figure II1B in the online-only Data Supplement). If a central venous line was available, normovolemia (central venous pressure 5-8 mm Hg) was achieved by supplemental fluid administration.…”

Section: Treatment Algorithmsmentioning

confidence: 99%

Early Intensive Versus Minimally Invasive Approach to Postoperative Hemodynamic Management After Subarachnoid Hemorrhage

Mutoh

Kazumata

Terasaka

et al. 2014

Self Cite

The results of previous studies suggest that early goal-directed fluid therapy (EGDT) reduces the incidence of DCI after aneurysmal SAH, 10,14 but the effects of EGDT on clinical outcomes are still unclear. This prospective study aimed to determine whether EGDT improves outcomes compared with standard less-invasive hemodynamic therapy. The outcomes after EGDT were also evaluated in subgroups of patients with poor clinical grade 10,11,15 or concurrent cardiopulmonary complications, [16][17][18] which are well-known risk factors for DCI and poor outcome. Methods Patient SelectionThis 2-center, prospective, randomized, nonblinded clinical trial enrolled patients who were admitted for the treatment of SAH at Teine Keijinkai Hospital and the Research Institute for Brain and Blood Vessels-AKITA between April 2009 and September 2013. Patients were screened for enrollment after obliteration of the causative aneurysm. The inclusion and exclusion criteria are shown in Figure I and Background and Purpose-The results of previous studies suggest that early goal-directed fluid therapy (EGDT) reduces delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage, but the effects of EGDT on clinical outcomes are still unclear. This study aimed to determine whether EGDT improves outcomes compared with standard less-invasive hemodynamic therapy. Methods-This study included 160 patients treated within 24 hours after subarachnoid hemorrhage, randomized to receive either (1) EGDT guided by preload volume and cardiac output monitored by transpulmonary thermodilution (treatment group) or (2) standard therapy guided by fluid balance or central venous pressure, assisted by uncalibrated less-invasive cardiac output monitoring during hyperdynamic therapy in patients with clinical or radiological indications of DCI (control group). DCI determined by clinical or radiological findings and functional outcome determined by the modified Rankin Scale score at 3 months were compared between groups. Results-For all clinical grades combined, there were no significant differences in the rates of DCI (33% versus 42%; P=0.33) or modified Rankin Scale score of 0 to 3 at 3 months (67% versus 57%; P=0.