The effect of the volemic and cardiac status on brain oxygenation in patients with subarachnoid hemorrhage: a bi-center cohort study

Background

Fluid management in patients after subarachnoid hemorrhage (SAH) aims at the optimization of cerebral blood flow and brain oxygenation. In this study, we investigated the effects of hemodynamic management on brain oxygenation by integrating advanced hemodynamic and invasive neuromonitoring

Methods

This observational cohort bi-center study included data of consecutive poor-grade SAH patients who underwent pulse contour cardiac output (PiCCO) monitoring and invasive neuromonitoring. Fluid management was guided by the transpulmonary thermodilution system and aimed at euvolemia (cardiac index, CI ≥ 3.0 L/min/m^2; global end-diastolic index, GEDI 680–800 mL/m^2; stroke volume variation, SVV < 10%). Patients were managed using a brain tissue oxygenation (P_btO_2) targeted protocol to prevent brain tissue hypoxia (BTH, P_btO_2 < 20 mmHg). To assess the association between CI and P_btO_2 and the effect of fluid challenges on CI and P_btO_2, we used generalized estimating equations to account for repeated measurements

Results

Among a total of 60 included patients (median age 56 [IQRs 47–65] years), BTH occurred in 23% of  the monitoring time during the first 10 days since admission. Overall, mean CI was within normal ranges (ranging from 3.1 ± 1.3 on day 0 to 4.1 ± 1.1 L/min/m^2 on day 4). Higher CI levels were associated with higher P_btO_2 levels (Wald = 14.2; p  < 0.001). Neither daily fluid input nor fluid balance was associated with absolute P_btO_2 levels ( p  = 0.94 and p  = 0.85, respectively) or the occurrence of BTH ( p  = 0.68 and p  = 0.71, respectively). P_btO_2 levels were not significantly different in preload dependent patients compared to episodes of euvolemia. P_btO_2 increased as a response to fluid boluses only if BTH was present at baseline (from 13 ± 6 to 16 ± 11 mmHg, OR = 13.3 [95% CI 2.6–67.4], p  = 0.002), but not when all boluses were considered ( p  = 0.154)

Conclusions

In this study a moderate association between increased cardiac output and brain oxygenation was observed. Fluid challenges may improve P_btO_2 only in the presence of baseline BTH. Individualized hemodynamic management requires advanced cardiac and brain monitoring in critically ill SAH patients.