Abstract 4576: Validation and Clinical Outcome of Less Invasive Goal-Directed Hemodynamic Management by the Transpulmonary Thermodilution in Patients after Subarachnoid Hemorrhage

Abstract

Assessment of cardiac output (CO) and intravascular volume is of high importance for adequate cerebral perfusion and oxygen delivery in patients suffering from cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH), but is often precluded by the invasiveness and complexity of a pulmonary artery catheter (PAC) placement. We sought to evaluate the utility of less invasive goal-directed volumetric and hemodynamic monitoring by advanced transpul-monary thermodilution (PiCCO ™ , Pulsion, Germany) utilizing only central venous and peripheral arterial catheters compared with standard circulatory management after SAH. One-hundred fourteen patients with SAH treated within 24 hours of ictus were investigated. Validation of transpulmonary dilution-derived intermittent and calibrated continuous CO (TPCO and PCCO) and cardiac preload (GEDV, global end-diastolic volume) were compared with PAC-derived reference CO (PACO), pulmonary capillary wedge pressure (PCWP), or central venous pressure (CVP) in 14 patients diagnosed with vasospasm. In a subsequent prospective trial of 100 cases, the clinical course and outcome of this method (n=53) was compared to those of CVP or PCWP and PACO guided conventional therapy (n=47), after the establishment of each fluid protocol for treatment of vasospasm (triple-H therapy). TPCO and PCCO (indexed to the BSA) showed excellent correlation ( r = .91 and .86) and small bias (+0.07 and +0.24 L/min/m 2 ) with a low percentage error (10.2 and 12.4%), when compared to PACO. The relationship between GEDV and stroke volume in response to defined volume loading was stronger ( r = .71) than that between CVP or PCWP and stroke volume ( r = .16 and .26). Frequency of cardiopulmonary complications (0 vs 10%) and vasospasm-related cerebral infarction (9 vs 17%), amount of daily fluid intake (4,210±968 vs 5,681±1,019 mL), and length of ICU stay (14±2 vs 17±2 days) were significantly reduced (p<0.05) in the transpulmonary themodilution group. Transpulmonary thermodilution enables clinically acceptable monitoring in patients following SAH. Goal-directed therapy guided by the volumetric and hemodynamic parameters with this method has a potential advantage over conventional methods.