Abstract
Management of volume status, arterial blood pressure, and cardiac output are core elements in approaching the patients with aneurysmal subarachnoid hemorrhage (SAH). For the prevention and treatment of delayed cerebral ischemia (DCI), euvolemia is advocated and caution is made towards the avoidance of hypervolemia. Induced hypertension and cardiac output augmentation are the mainstays of medical management during active DCI, whereas the older triple-H paradigm has fallen out of favor due to lack of demonstrable physiological or clinical benefits and serious concern for adverse effects such as pulmonary edema and multiorgan system dysfunction. Furthermore, insight into clinical hemodynamics of patients with SAH becomes salient when one considers the frequently associated cardiac and pulmonary manifestations of the disease such as SAH-associated cardiomyopathy and neurogenic pulmonary edema. In terms of fluid and volume targets, less attention has been paid to dynamic markers of fluid responsiveness despite the well-established, in the general critical care literature, superiority of these as compared to traditionally used static markers such as central venous pressure (CVP). Based on this literature and sound pathophysiologic reasoning, reliance on static markers (such as CVP) is unjustified when one attempts to assess strategies augmenting stroke volume (SV), arterial blood pressure, and oxygen delivery. There are several options for continuous bedside cardiorespiratory monitoring and optimization of SAH patients. We, here, review a noninvasive monitoring technique based on thoracic bioreactance and focusing on continuous cardiac output and fluid responsiveness markers.
Highlights
Delayed cerebral ischemia (DCI), after aneurysmal subarachnoid hemorrhage (SAH), affects approximately 30% of patients [1]
The common practice of relying on hourly or daily fluid balances has been shown to be poorly indicative of effective circulating blood volume (which is the variable of interest as a fundamental determinant of cardiac output (CO) and its ability to vary in response to changing metabolic demands) [4, 5]. is often translates into highly subjective, clinician, and institution-specific fluid management targets [6, 7]
We aim to review a technology based on thoracic bioreactance that provides noninvasive, continuous bedside measurements and monitoring of cardiac index (CI) and dynamic markers of fluid responsiveness, report our pilot study on bioreactance-based fluid responsiveness and cardiac output monitoring in ten patients with aneurysmal subarachnoid hemorrhage, and provide a narrative review of the literature
Summary
Delayed cerebral ischemia (DCI), after aneurysmal subarachnoid hemorrhage (SAH), affects approximately 30% of patients [1]. Is often translates into highly subjective, clinician, and institution-specific fluid management targets [6, 7]. It commonly results in the administration of excessive fluid volumes subjecting patients to the risks of systemic complications such as hypoxemic respiratory failure, kidney injury, and counterproductively decreased cerebral oxygen delivery and worse neurological outcome [8,9,10,11]. Monitoring and manipulation of effective circulating volume and CO is relevant for the prevention and treatment of DCI and becomes important in understanding and managing SAH-related cardiorespiratory complications such as stress cardiomyopathy and neurogenic pulmonary edema. Monitoring and manipulation of effective circulating volume and CO is relevant for the prevention and treatment of DCI and becomes important in understanding and managing SAH-related cardiorespiratory complications such as stress cardiomyopathy and neurogenic pulmonary edema. e presence of these complications in a patient with
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