Optimal Range of Global End-Diastolic Volume for Fluid Management After Aneurysmal Subarachnoid Hemorrhage

Tagami, Takashi; Kuwamoto, Kentaro; Watanabe, Akihiro; Unemoto, Kyoko; Yokobori, Shoji; Matsumoto, Gaku; Yokota, Hiroyuki

doi:10.1097/ccm.0000000000000163

Cited by 53 publications

(35 citation statements)

References 47 publications

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“…Yoneda et al 39 reported that patients with DCI exhibit a decreased GEDI in the early stage of SAH (i.e., Days 3-5). Meanwhile, Tagami et al 35 demonstrated that the mean GEDI is an independent predictor of the occurrence of pulmonary edema, and a GEDI of > 921 ml/m 2 is significantly associated with the development of severe pulmonary edema. In addition, an ELWI of > 10 ml/kg is more accurate for diagnosing pulmonary edema than clinical symptoms or chest radiograph findings.…”

Section: Discussionmentioning

confidence: 99%

A multicenter prospective cohort study of volume management after subarachnoid hemorrhage: circulatory characteristics of pulmonary edema after subarachnoid hemorrhage

Obata

Takeda

Sato

et al. 2016

JNS

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S ubarachnoid hemorrhage (SAH) from a ruptured aneurysm is accompanied by several complications, including electrolyte abnormalities, vasospasm, hydrocephalus, cardiac dysfunction, and pulmonary edema. 15,16,18 Among these complications, delayed cerebral ischemia (DCI) remains an important cause of morbidity and death. 15 Many studies have investigated the prevention or treatment of DCI after SAH.Triple-H therapy (i.e., hypertension, hypervolemia, and hemodilution) has reportedly been an effective approach abbreviatioNs CI = cardiac index; CRP = C-reactive protein; DCI = delayed cerebral ischemia; ELWI = extravascular lung water index; GEDI = global end-diastolic volume index; PVPI = pulmonary vascular permeability index; SAH = subarachnoid hemorrhage; SVRI = systemic vascular resistance index; WFNS = World Federation of Neurosurgical Societies. obJective Subarachnoid hemorrhage (SAH) is often accompanied by pulmonary complications, which may lead to poor outcomes and death. This study investigated the incidence and cause of pulmonary edema in patients with SAH by using hemodynamic monitoring with PiCCO-plus pulse contour analysis. methods A total of 204 patients with SAH were included in a multicenter prospective cohort study to investigate hemodynamic changes after surgical clipping or coil embolization of ruptured cerebral aneurysms by using a PiCCO-plus device. Changes in various hemodynamic parameters after SAH were analyzed statistically. results Fifty-two patients (25.5%) developed pulmonary edema. Patients with pulmonary edema (PE group) were significantly older than those without pulmonary edema (non-PE group) (p = 0.017). The mean extravascular lung water index was significantly higher in the PE group than in the non-PE group throughout the study period. The pulmonary vascular permeability index (PVPI) was significantly higher in the PE group than in the non-PE group on Day 6 (p = 0.029) and Day 10 (p = 0.011). The cardiac index of the PE group was significantly decreased biphasically on Days 2 and 10 compared with that of the non-PE group. In the early phase (Days 1-5 after SAH), the daily water balance of the PE group was slightly positive. In the delayed phase (Days 6-14 after SAH), the serum C-reactive protein level and the global end-diastolic volume index were significantly higher in the PE group than in the non-PE group, whereas the PVPI tended to be higher in the PE group. coNclusioNs Pulmonary edema that occurs in the early and delayed phases after SAH is caused by cardiac failure and inflammatory (i.e., noncardiogenic) conditions, respectively. Measurement of the extravascular lung water index, cardiac index, and PVPI by PiCCO-plus monitoring is useful for identifying pulmonary edema in patients with SAH.Clinical trial registration no.: UMIN000003794 (clinicaltrials.gov)http://thejns.org/doi/abs/10.3171/2015.6.JNS1519

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Section: Discussionmentioning

confidence: 99%

A multicenter prospective cohort study of volume management after subarachnoid hemorrhage: circulatory characteristics of pulmonary edema after subarachnoid hemorrhage

Obata

Takeda

Sato

et al. 2016

JNS

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“…They further asserted that the decision to administer a fluid challenge should reflect the baseline SVV and brain tissue oxygen pressure response to the fluid challenge. Another study demonstrated that mean global end-diastolic volume index (normal range 680–800 ml/m 2 ) was an independent risk factor for the development of DCI (when less than 820 ml/m 2 ) and pulmonary edema (when greater than 921 ml/m 2 ) [4 ▪▪ ]. The authors concluded that global end-diastolic volume index should be maintained slightly above normal during fluid management of patients with SAH.…”

Section: Hemodynamic Managementmentioning

confidence: 99%

Postoperative ICU management of patients after subarachnoid hemorrhage

Gruenbaum

Bilotta²

2014

Current Opinion in Anaesthesiology

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Purpose of review This article reviews recent advances in the postoperative ICU management of patients after subarachnoid hemorrhage (SAH), especially with regards to hemodynamic management, methods of improving neurological outcomes, and management of cardiac and pulmonary complications. Recent findings Several hemodynamic monitors and parameters may be useful for guiding volume therapy, including cardiac output, stroke volume variation monitoring, and global end-diastolic volume index. Early goal-directed hemodynamic therapy after SAH has recently been shown to improve clinical outcomes in patients with a poor clinical grade or coexisting cardiopulmonary complications. Recent laboratory and imaging modalities are being developed to identify patients at risk for developing vasospasm after SAH. Evidence for the use of various prophylactic adjuvant therapies to prevent vasospasm, including magnesium, phosphodiesterase 3 inhibitors, and therapeutic hypothermia, is emerging. Intrathecal administration of vasodilators or fibrinolytics may have offered advantages over systemic drug administration in the treatment of vasospasm. Pulmonary and cardiac complications are common after SAH, and are associated with an increased risk of mortality. Summary The postoperative ICU period after SAH is associated with a significant morbidity and mortality risk, and recent studies have greatly contributed to our understanding of how to optimally manage these patients.

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“…In their recent study including 204 SAH patients, Yoneda et al [39] showed that the cardiac index measured by transpulmonary thermodilution was significantly lower in patients with poor-grade aSAH and that patients developing DCI had a significantly lower global enddiastolic volume index (GEDI) than patients without these neurological sequelae. The same study group was able to show that the GEDI was an independent risk factor associated with the occurrence of DCI and severe pulmonary edema [40], the Scylla and Charybdis of volume therapy in aSAH. They found a lower threshold of 822 ml/m 2 , slightly above the normal range, correlated with an increased risk of DCI.…”

Section: Subarachnoidal Hemorrhagementioning

confidence: 93%

“…They found a lower threshold of 822 ml/m 2 , slightly above the normal range, correlated with an increased risk of DCI. A GEDI threshold above 921 ml/m 2 was best correlated with the occurrence of severe pulmonary edema in 47 of 180 patients after aSAH [40]. The infusion of crystalloid or colloid infusion to increase the cardiac index and raise GEDI above normal values reduced DCI and improved postoperative functional outcome in poor-grade SAH patients [41].…”

Section: Subarachnoidal Hemorrhagementioning

confidence: 94%