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

Abstract

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.

Acute cardiac support with intravenous milrinone promotes recovery from early brain injury in a murine model of severe subarachnoid haemorrhage

“…The therapeutic approach of MIL‐mediated cardiac support used here is clinically relevant because we employed an established protocol to reverse DCI without adverse cardiopulmonary complications . In fact, at this dose range (0.25‐0.75 μg/kg/min) no animals died during postconditioning or presented MRI‐evidenced rebleeding on final examination (Figure B), which is in good agreement with our previous findings using dobutamine .…”

Is mean arterial pressure the best parameter in ischemic stroke?

“…In accordance with these results SAH‐patients with poor cardiac function were more likely than patients with good cardiac function to experience infarction due to vasospasms . Furthermore, it could be shown that optimizing hemodynamic parameters (preload, CI) effects a better outcome . Furthermore, optimizing CI lead to an improvement of CP .…”

Postoperative ICU management of patients after subarachnoid hemorrhage

“…A recent study compared functional outcomes in 160 patients after receiving either early goal-directed therapy guided by preload volume and cardiac output or monitoring with standard therapy [2 ▪▪ ]. In SAH patients with a poor clinical grade or coexisting cardiopulmonary complications, early goal-directed therapy reduced the likelihood of developing DCI and improved clinical outcomes.…”