Fluid management of

Neurosurgical patient,
Recent update
Catholic University of Daegu
Department of anesthesiology and pain medicine

Taeha. Ryu.
 Fluid management of
Neurosurgical patient
• The major aims ….
– minimize the risk for inadequate CPP
– maintain good neurosurgical conditions

• Volume status
– Hypervolemia → cerebral edema
– Hypovolemia → hypotension
→ CPP ↓, cerebral edema ↑
Overview of the two main barriers
in the CNS

Particle and Fibre Toxicology 2010, 7:3

Schematic diagram of capillary
membrane
 Recent debates in fluid
management
• Normal Saline vs Balanced Solutions
• Colloids vs Crystalloids
• Restricted vs Conventional
• Goal directed vs Conventional
• Monitoring for fluid status
 To be discussed
1. Choice of fluids
A. Contents of crystalloids; balanced vs normal
saline
B. Colloids vs crystalloids
2. Amounts of fluids
A. Goal directed vs conventional, restrictive vs
conventional
3. The means to monitor the effect of fluid
therapy
A. monitors for fluid status; cost, risk
Balanced sloution vs Normal saline
CONTENTS OF FLUIDS
 General Principles of Fluid Management
for Neurosurgical Patients
1. Maintain Normovolemia

2. Avoid reduction of serum osmolarity

Miller’s anesthesia 7th

 Electrolyte Concentraions
0.9% Lactated Plasmalyte Normosol-
Plasma
Saline Ringer’s 148 or A R
Sodium 154 130 140 140 134-145
Potassium 0 4 5 5 3.4-5
Chloride 154 109 98 98 98-108
Calcium 0 2.7 0 0 2.25-2.65
27 (acetate)
Bicarbonate 0 0 0 22-32
23 (gluconate)
Lactate 0 28 0 0
Magnesium 0 0 3 3 0.7-1.1
Osmolarity 308 273 294 295 280-295
Osmolarity and cerebral edema

Anesthesiology 1987 67:6

Recommendation 1

Because of the risk of

inducing hyperchloraemic
acidosis in routine practice,
when crystalloid resuscitation
or replacement is indicated,
balanced salt solutions e.g.
Ringer’s lactate/acetate or
Hartmann’s solution should
replace 0.9% saline, except in
cases of hypochloraemia e.g.
from vomiting or gastric
drainage.

Evidence level 1b
 Normal Saline
• Non-glucose containg
• Non-Calcium containg
• Reconstituting packed RBC
• Is normal saline normal?
– Slightly hyperoncotic
– Hyprechloremic normal-anion gap acidosis
Perioperative buffered versus non-buffered fluid
administration for surgery in adults (Review)

Burdett, Dushianthan et al. 2012

 Hyperchloremia After Noncardiac Surgery Is
Independently Associated with Increased Morbidity
and Mortality: A Propensity-Matched Cohort Study

McCluskey, Karkouti et al. 2013

 Balanced vs chloride-rich solutions for fluid
resuscitation in brain-injured patients: a
randomised double-blind pilot study
• Single-center, two-arm, randomised,
double-blind, pilot controlled trial
• Patients with severe TBI(GCS ≤8) or SAH
(WFNS<III) who were mechanically
ventilated.
• isotonic balanced solutions or isotonic
sodium chloride solutions for 48 hours.

Roquilly et al. Critical Care 2013, 17:R77

Balanced vs chloride-rich solutions for fluid
resuscitation in brain-injured patients: a
randomised double-blind pilot study

Roquilly et al. Critical Care 2013, 17:R77

Balanced vs chloride-rich solutions for fluid
resuscitation in brain-injured patients: a
randomised double-blind pilot study

Roquilly et al. Critical Care 2013, 17:R77

Balanced vs chloride-rich solutions for fluid
resuscitation in brain-injured patients: a
randomised double-blind pilot study

Roquilly et al. Critical Care 2013, 17:R77

Balanced vs chloride-rich solutions for fluid
resuscitation in brain-injured patients: a
randomised double-blind pilot study

Roquilly et al. Critical Care 2013, 17:R77

COLLOIDS VS CRYSTALLOIDS
 Human albumin solution for resuscitation and
volume expansion in critically ill patients.
Outcome; Deaths
Subgroup; hypovolemia

Roberts, Blackhall et al. Cochrane Database Syst Rev. 2011

Human albumin solution for resuscitation and
volume expansion in critically ill patients.

Outcome; Deaths
Subgroup; Burn

Outcome; Deaths
Subgroup; Hypoalbuminemia

Roberts, Blackhall et al. Cochrane Database Syst Rev. 2011

 Colloids vs crystalloids for fluid
resuscitation in critically ill patients
Outcome; Deaths

Colloids compared to crystalloids

Perel, Roberts et al. 2013

 Colloid solutions for fluid
resuscitation
Albumin or PPF vs HES, Outcome Death.

Albumin or PPF vs gelatin, Outcome Death.

Bunn and Trivedi 2012

 Colloid solutions for fluid
resuscitation
Albumin or PPF vs dextran, Outcome Death.

Modified gelatin vs HES, Outcome Death.

Modified gelatin vs dextran, Outcome Death

Bunn and Trivedi 2012

 The NEW ENGLAND JOURNAL of MEDICINE

HES 130/0.42 vs Ringer’s Acetate in Severe Sepsis

The 6S trial

The 6S trial, Perner, Haase et al. 2012

 The NEW ENGLAND JOURNAL of MEDICINE

HES 103/0/4 or Saline for Fluid Resuscitation in ICU

CHEST trial

CHEST trial, Myburgh, Finfer et al. 2012

INTENSIVE CARE MEDICINE

Fluid resuscitation with 6 % HES (130/0.4 and

130/0.42) in acutely ill patients: systematic review
Forest plot for mortality

Gattas, Dan et al. 2013

INTENSIVE CARE MEDICINE

Fluid resuscitation with 6 % HES (130/0.4 and

130/0.42) in acutely ill patients: systematic review
Forest plot need for RRT

Gattas, Dan et al. 2013

 Assessment of hemodynamic efficacy and safety of 6%
HES 130/0.4 vs. 0.9% NaCl fluid replacement in patients
with severe sepsis: The CRYSTMAS study

Efficacy outcome
HES 130/0.4 NaCl 0.9%
P
(n=88) (n=86)

1,379 1,709
Mean volume of study drug used, ml (SD) 0.0185
(886) (1,164)

11.8 14.3
Mean time to initial HDS, hours (SD) NS
(11.1) (11.1)

Number of patients prescribed IV

88 (88.0) 87 (90.6) NS
catecholamines (%)

Guidet, Martinet et al. 2012

 Assessment of hemodynamic efficacy and safety of 6%
HES 130/0.4 vs. 0.9% NaCl fluid replacement in patients
with severe sepsis: The CRYSTMAS study
Outcomes
HES 130/0.4 NaCl 0.9% P

LOS in the ICU (days) 15.4 ± 11.1 20.2 ± 22.2 NS

LOS in the hospital (days) 37.7 ± 26.5 42.7 ± 31.6 NS

The AUC of the SOFA Score 6.9 ± 3.3 7.6 ± 3.1 NS

31/100
Mortality rate until day 28 24/95 (25.3%) 0.37
(31.0 %)

Mortality rate until day 90 40/99 (40.0%) 32/95 (34%) 0.33

Guidet, Martinet et al. 2012

 Assessment of hemodynamic efficacy and safety of 6%
HES 130/0.4 vs. 0.9% NaCl fluid replacement in patients
with severe sepsis: The CRYSTMAS study
 ARF occurred in 24 (24.5%) and 19 (20%) patients for HES and NaCl,
respectively (P = 0.454).
 Number of patients by the AKIN and RIFLE classifications

Guidet, Martinet et al. 2012

JAMA
Effects of Fluid Resuscitation With Colloids vs Crystalloids on
Mortality in Critically Ill Patients Presenting With Hypovolemic Shock
CRISTAL study
Cumulative Incidence of Death Within First 28 Days
After Randomization

Annane, Siami et al. 2013

JAMA
Effects of Fluid Resuscitation With Colloids vs Crystalloids on
Mortality in Critically Ill Patients Presenting With Hypovolemic Shock
CRISTAL study

Annane, Siami et al. 2013

JAMA
Effects of Fluid Resuscitation With Colloids vs Crystalloids on
Mortality in Critically Ill Patients Presenting With Hypovolemic Shock
CRISTAL study

Annane, Siami et al. 2013

Drugs in R&D

Bioequivalence Comparison between Hydroxyethyl Starch

130/0.42/6 : 1 and Hydroxyethyl Starch 130/0.4/9 : 1

Lehmann, Marx et al. 2007

Drugs in R&D

Bioequivalence Comparison between Hydroxyethyl Starch

130/0.42/6 : 1 and Hydroxyethyl Starch 130/0.4/9 : 1

Lehmann, Marx et al. 2007

EJA
Effects of balanced HES solutions on gut mucosal
microcirculation and exhaled nitric oxide in septic rats

Total capillary perfusion.

Intercapillary area (ICA) between all perfused
capillaries (ICAtotal)

(*P<0.05 vs crystalloid).
Langanke, Hinkelmann et al. 2013
EJA
Effects of balanced HES solutions on gut mucosal
microcirculation and exhaled nitric oxide in septic rats

Exhaled nitric oxide

Exhaled nitric oxide was used

used as a surrogate marker for
pulmonary inflammation.

The lowest exhaled nitric oxide

concentrations were recorded
after waxy maize bolus resuscitation only

(*P<0.05 vs crystalloid).
Langanke, Hinkelmann et al. 2013
INTENSIVE CARE MEDICINE

Consensus statement of the ESICM task force on

colloid volume therapy in critically ill patients

Reinhart, Perner et al. 2012

 Performance of Bedside Transpulmonary Thermodilution
Monitoring for Goal-Directed Hemodynamic Management After
Subarachnoid Hemorrhage

• Early goal-directed therapy for the

patients c vasospasm after SAH
• 116 patients / after surgical clipping
• PAC vs PiCCO
• Validation study; 16 patients
• Clinical Assessment study; 100 patients

Mutoh, Kazumata et al. 2009

 Performance of Bedside Transpulmonary Thermodilution
Monitoring for Goal-Directed Hemodynamic Management After
Subarachnoid Hemorrhage

Mutoh, Kazumata et al. 2009

 Performance of Bedside Transpulmonary Thermodilution
Monitoring for Goal-Directed Hemodynamic Management After
Subarachnoid Hemorrhage

Mutoh, Kazumata et al. 2009

 Performance of Bedside Transpulmonary Thermodilution
Monitoring for Goal-Directed Hemodynamic Management After
Subarachnoid Hemorrhage

PiCCO Conventional P

Vasospasm 50% 66% 0.03

DIND 32% 48% 0.03

Vasospasm related cbr

6% 14% 0.049
infarction
Modified Rankin Scale Score
56% 44% 0.0598
at 3Mos 0 to 3
Medical therapy-related
cardiopulmonary 2% 12% 0.01
complications

DIND: delayed ischemic neurological deficit

Mutoh, Kazumata et al. 2009
Effect of human albumin administration on clinical outcome
and hospital cost in patients with subarachnoid hemorrhage

Suarez, Shannon et al. 2004

 The NEW ENGLAND JOURNAL of MEDICINE

A Comparison of Albumin and Saline for Fluid

Resuscitation in the Intensive Care Unit
- The SAFE Study Investigators -

Status at 28 days Albumin Saline RR (95% CI) P value

No.Death/No.Total (%)
81/596 59/590 1.36
Overall 0.06
(13.6%) (10.0%) (0.99-1.86)
Trauma 59/241 38/251 0.62
TBI 0.009
(24.5%) (15.1%) (1.12-2.34)
22/355 21/339 1.00
No BI 1.00
(6.2%) (6.2%) (0.56-1.79)
0.96
No Trauma 641/2831 666/2830 0.04
(0.88-1.06)

Finfer, Bellomo et al. 2004

 The NEW ENGLAND JOURNAL of MEDICINE

Saline or Albumin for Fluid Resuscitation in Patients

with Traumatic Brain Injury
- The SAFE Study Investigators -

Kaplan–Meier Estimates of the Probability of Survival

• P = 0.007 for each by the log-rank test

Myburgh, Cooper et al. 2007

 The NEW ENGLAND JOURNAL of MEDICINE

Saline or Albumin for Fluid Resuscitation in Patients

with Traumatic Brain Injury
- The SAFE Study Investigators -

Myburgh, Cooper et al. 2007

 Albumin Resuscitation for TBI: Is Intracranial
Hypertension the Cause of Increased Mortality?

Cooper, Myburgh et al. 2013

Fluid resuscitation in patients with traumatic
brain injury: what is a SAFE approach?

Van Aken, Kampmeier et al. 2012

 The ALIAS Pilot Trial
A Dose-Escalation and Safety Study of Albumin Therapy for Acute
Ischemic Stroke—II: Neurologic Outcome and Efficacy Analysis

Palesch, Hill et al. 2006

High-dose albumin treatment for acute ischaemic
stroke (ALIAS) part 2: a randomised, double-blind,
phase 3, placebo-controlled trial

Ginsberg, Palesch et al. 2013

The Albumin in Subarachnoid Hemorrhage (ALISAH)
Multicenter Pilot Clinical Trial: Safety and Neurologic
Outcomes

Suarez, Martin et al. 2012

Goal directed fluid managements
AMOUNTS OF FLUIDS
‘Liberal’ vs. ‘restrictive’ perioperative fluid therapy
– a critical assessment of the evidence
Liberal vs. restrictive fixed-volume regimens are not well defined in the literature
regarding the definition, methodology and results, and lack the use of or
information on evidence-based standardized perioperative care-principles (fast-track
surgery), thereby precluding evidence-based guidelines for procedure-specific
perioperative fixed-volume regimens.

Bundgaard-Nielsen, Secher et al. 2009

INTENSIVE CARE MEDICINE

Goal-directed therapy in high-risk surgical

patients: a 15-year follow-up study

Independent factors
affecting
the long term survival

Age
; HR 1.04, p<0.0001

Randomization to the GDT

; HR 0.61, p=0.02

Postop Cardiac Cx
; HR 3.78, p=0.007

Rhodes, Cecconi et al. 2010

Maintaining Tissue Perfusion in High-Risk Surgical
Patients: A Systematic Review of RCTs
 Optimising stroke volume and oxygen delivery in
abdominal aortic surgery: a randomised controlled trial

Bisgaard, Gilsaa et al. 2013

Hamilton, Cecconi et al. 2011
 Corcoran, Rhodes et al. 2012

Length of Stay
 Corcoran, Rhodes et al. 2012

Pneumonia
 Corcoran, Rhodes et al. 2012

Renal Complications
 Corcoran, Rhodes et al. 2012

time to first bowel movement (days)

time to resumption of normal diet (days)

 Stroke Volume Variation as a Predictor of Fluid
Responsiveness in Patients Undergoing Brain Surgery

Berkenstadt, Margalit et al. 2001

Delta down compared with delta pulse pressure as an
indicator of volaemia during intracranial surgery

Deflandre, Bonhomme et al. 2008

 Evaluation of SVV Obtained by the FloTrac™/Vigileo™
System to Guide Preoperative Fluid Therapy in Patients
Undergoing Brain Surgery

Li, Ji et al. 2012

 Performance of Third-generation
FloTrac/Vigileo system during hyperdynamic therapy
for delayed cerebral ischemia after SAH

Mutoh, Ishikawa et al. 2012

HYPERTONIC SALINE
MANNITOL
A comparison of the cerebral and hemodynamic effects
of mannitol and hypertonic saline in a rabbit model of
acute cryogenic brain injury

Scheller, Zornow et al. 1991

Comparison of mannitol and hypertonic saline in the
treatment of severe brain injuries

Sakellaridis, Pavlou et al. 2011

Critical Care Medicine

Hypertonic saline versus mannitol for the treatment of elevated

intracranial pressure: A meta-analysis of randomized clinical trials

relative risk (RR) of successful control difference in mean quantitative

of elevated intracranial pressure reduction of intracranial pressure

Kamel, Navi et al. 2011

Hypertonic saline for treating raised intracranial pressure:
literature review with meta-analysis

Mortazavi, Romeo et al. 2012

Thank you.