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Abstract

Introduction: Predictive variables of death after subarachnoidal hemorrhage (SAH) are still unknown and Goal-Directed Fluid Management has still not been established for this cohort of patients systematically. Nevertheless, hemodynamic changes seem to be associated with death after SAH. Methods: Data of 137 patients who have been admitted to our neurosurgical ICU after aneurysmatic SAH receiving a Goal-Directed Fluid Management using PiCCO monitoring from July 2006 to December 2011 has been analyzed retrospectively. The patient cohort was divided in group 1 including patients who survived and group 2 including patients who died during hospital stay. Parameters such as initial, minimal and maximal Cardiac Index (CI), Extravascular Lung Water Index (ELWI) and Intrathoracic Blood Volume Index (ITBI) and the difference between maximal and minimal of these parameters as a dynamic component were compared among the two groups. Additional the Kidney Disease: Improving Global Outcomes (KDIGO) criteria were provided for both groups. Results: Of the 137 patients included in this analysis 91 (66,4%) survived and 46 (33,6%) died during hospital stay. There was no difference concerning age, sex, body weight and height between the two groups. Initial CI (4,1 ± 1,2 vs. 3,9 ± 1,5) and ITBI (997 ± 284,3 vs. 992,5 ± 225,5) were similar whereas initial ELWI was significantly elevated in group 2 (7,9 ± 4,3 vs. 13 ± 7,4; p<0,01). The minimal CI was lower (3,7 ± 1,2 vs. 3,2 ± 1,4; p<0,05), minimal and maximal ELWI were higher in group 2 (7,5 ± 4,2 vs. 11,7 ± 6,6; p<0,01 and 9,3 ± 5,6 vs. 16,2 ± 10,9; p<0,01). Moreover the difference of maximal and minimal ELWI during study time was elevated significantly in the group related to death (2,2 ± 4,1 vs. 5 ± 6,7; p<0,05). Renal failure by KDIGO criteria was observed more often in group 2 (0,36 ± 0,97 vs. 1,93 ± 1,44, p<0,01) and was significant correlated with initial (r=0,57; p<0,01), minimal (r=0,59; p<0,01) and maximal (r=0,55; p<0,01) ELWI. Conclusions: To our knowledge this is the first study which demonstrates that variables like CI and especially ELWI using transpulmonary thermodulation for Goal-Directed Fluid management in patients with SAH seem to have a predictive value for mortality. Elevated initial ELWI after SAH and higher changes in ELWI during hemodynamic therapy are associated with a higher rate of death due to pulmonary edema, renal failure or delayed cerebral ischema caused by fluid overload as shown in recent studies.