Long-Term Outcome Call into Question the Benefit of Positive Fluid Balance and Colloid Treatment After Aneurysmal Subarachnoid Hemorrhage

Abstract

Aneurysmal subarachnoid hemorrhage (SAH) has a high mortality and morbidity, and long-term outcome is determined by the functional capacity of the patient. Preventing delayed cerebral ischemia that will result in delayed ischemic neurological deficits (DINDs) is a paramount treatment goal during the post-hemorrhage period. There is still controversy regarding the best strategies. While therapeutic induction of hypertension, hypervolemia, and hemodilution (‘‘Triple-H therapy’’) is the most commonly accepted treatment, uncertainty remains, among others, whether colloids versus crystalloids should be utilized, and whether maintaining a positive fluid balance in patients with evidence for vasospasm improves long-term functional outcome. Ibrahim and Macdonald [1] approached the problem by conducting a post-hoc analysis of an existing large database (n = 413; CONSCIOUS-1 trial [2]). First, they used propensity-score matching to determine whether the administration of colloids between days 3 and 14 (period of the highest risk for cerebral vasospasm/DIND after SAH) influences the incidence of DIND and of delayed infarction, and whether it influences the functional outcome 6–12 weeks after SAH (Glasgow outcome scale, modified Rankin scale [mRs], and NIH stroke scale [NIHSS]). Next, using a multivariate logistic regression model, they evaluated any association that an overall fluid balance during the DIND risk period (3–14 days) has on the same outcome parameters. They found that treatment with colloids during the DIND risk period does not reduce the risk for DIND or delayed cerebral infarcts, but that it rather was associated with worse functional outcomes (NIHSS). Equally important, they found that a positive fluid balance during the DIND risk period was associated with prolonged length of stay in the ICU and worse functional outcome (mRS) at 12 months after SAH. However, they also found that patients with angiographic evidence of severe vasospasm had more delayed cerebral infarcts when their fluid balance remained negative during the DIND risk period. The authors conclude that the volume status of patients after SAH should be managed carefully and colloids should be restricted to selected patients and administered only under careful monitoring. Their findings are clinically important despite the limitations of post-hoc analysis. The study has relevance for several reasons: First, over the last several years in the medical literature, studies have surfaced regarding the negative effects of IV fluid over-resuscitation. This includes both positive fluid balance per day over an extended period of time during the hospitalization, as well as high ‘‘throughput’’ of IV fluids in the setting of an even fluid balance. It is now well documented that both management strategies are harmful in patients with sepsis, ARDS, after trauma or during the perioperative period [3–9]. However, the exact mechanism remains unclear. The new results presented by Ibrahim and Macdonald [1] suggest that equally, the injured brain may not be immune to the negative effects of fluid overadministration. Their results are particularly important, as it has been considered a gold standard of therapy to induce and maintain positive IV fluid balance in patients after SAH during the window of vasospasm, in order to prevent DIND. Interestingly enough the data suggest that even in This article is an editorial to 10.1007/S12028-013-9860-Z.