Abstract
BackgroundThe value of goal-directed fluid therapy in neurosurgical patients, where brain swelling is a major concern, is unknown. The aim of our study was to evaluate the effect of an intraoperative goal-directed fluid restriction (GDFR) strategy on the postoperative outcome of high-risk patients undergoing brain surgery.MethodsHigh-risk patients undergoing brain surgery were randomly assigned to a usual care group (control group) or a GDFR group. In the GDFR group, (1) fluid maintenance was restricted to 3 ml/kg/h of a crystalloid solution and (2) colloid boluses were allowed only in case of hypotension associated with a low cardiac index and a high stroke volume variation. The primary outcome variable was ICU length of stay, and secondary outcomes were lactates at the end of surgery, postoperative complications, hospital length of stay, mortality at day 30, and costs.ResultsA total of 73 patients from the GDFR group were compared with 72 patients from the control group. Before surgery, the two groups were comparable. During surgery, the GDFR group received less colloid (1.9 ± 1.1 vs. 3.9 ± 1.6 ml/kg/h, p = 0.021) and less crystalloid (3 ± 0 vs. 5.0 ± 2.8 ml/kg/h, p < 0.001) than the control group. ICU length of stay was shorter (3 days [1–5] vs. 6 days [3–11], p = 0.001) and ICU costs were lower in the GDFR group. The total number of complications (46 vs. 99, p = 0.043) and the proportion of patients who developed one or more complications (19.2 vs. 34.7%, p = 0.034) were smaller in the GDFR group. Hospital length of stay and costs, as well as mortality at 30 day, were not significantly reduced.ConclusionIn high-risk patients undergoing brain surgery, intraoperative GDFR was associated with a reduction in ICU length of stay and costs, and a decrease in postoperative morbidity.Trial registration Chinese Clinical Trial Registry ChiCTR-TRC-13003583, Registered 20 Aug, 2013
Highlights
The value of goal-directed fluid therapy in neurosurgical patients, where brain swelling is a major concern, is unknown
73 patients from the goal-directed fluid restriction (GDFR) group were compared to 72 patients from the control group
The GDFR group and the control group were comparable in terms of age, comorbidities, American Society of Anesthesiologists (ASA) score, and POSSUM score (Table 1)
Summary
The value of goal-directed fluid therapy in neurosurgical patients, where brain swelling is a major concern, is unknown. The amount of fluid administered during the perioperative period depends on multiple factors such as preoperative hydration, intraoperative blood loss, hemodynamic stability, as well as habits and believes of anesthesiologists and Whether such strategies may be useful in patients undergoing brain surgery is unknown. In this specific context, the temptation is to keep patients as dry as. We hypothesized that advanced hemodynamic measurements may be useful to objectively balance the risks of fluid restriction (hypovolemia, hypotension, and cerebral ischemia) with the risk of inducing or worsening cerebral edema [7, 8]. In line with this concept, we designed an intraoperative fluid management protocol where minimal fluid maintenance with a crystalloid solution (fluid restriction) was combined with the administration of fluid boluses in case of severe and documented hypovolemia
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