Goal-directed Fluid Therapy Versus Conventional Fluid Therapy During Craniotomy and Clipping of Cerebral Aneurysm: A Prospective Randomized Controlled Trial

Abstract

Background: Fluid imbalance is common after aneurysmal subarachnoid hemorrhage and negatively impacts clinical outcomes. We compared intraoperative goal-directed fluid therapy (GDFT) using left ventricular outflow tract velocity time integral (LVOT-VTI) measured by transesophageal echocardiography with central venous pressure (CVP)-guided fluid therapy during aneurysm clipping in aneurysmal subarachnoid hemorrhage patients.Methods: Fifty adults scheduled for urgent craniotomy for aneurysm clipping were randomly allocated to 2 groups: group G (n = 25) received GDFT guided by LVOT-VTI and group C (n = 25) received CVP-guided fluid management. The primary outcome was intraoperative mean arterial pressure (MAP). Secondary outcomes included volume of fluid administered and several other intraoperative and postoperative variables, including neurological outcome at hospital discharge and at 30 and 90 days.Results: There was no difference in MAP between the 2 groups despite patients in group G receiving lower volumes of fluid compared with patients in group C (2503.6 ± 534.3 vs. 3732.8 ± 676.5 mL, respectively; P < 0.0001). Heart rate and diastolic blood pressure were also comparable between groups, whereas systolic blood pressure was higher in group G than in group C at several intraoperative time points. Other intraoperative variables, including blood loss, urine output, and lac-tate levels were not different between the 2 groups. Postoperative variables, including creatinine, duration of postoperative mechanical ventilation, length of intensive care unit and hospital stay, and incidence of acute kidney injury, pneumonitis, and vasospasm were also comparable between groups. There was no difference in neurological outcome at hospital discharge (modified Rankin scale) and at 30 and 90 days (Extended Glasgow Outcome Scale) between the 2 groups. Conclusion:Compared with CVP-guided fluid therapy, transesophageal echocardiography-guided GDFT maintains MAP with lower volumes of intravenous fluid in patients undergoing clipping of intracranial aneurysms with no adverse impact on postoperative complications.

Pulse Pressure Variance (PPV)-Guided Fluid Management in Adult Patients Undergoing Supratentorial Tumor Surgeries: A Randomized Controlled Trial

“…6 Literature on GDFT in the neurosurgical population is limited with contradictory results. [11][12][13][23][24][25] Akin to our study, estimation of fluids by GDFT has led to a lesser intraoperative fluid requirement than conventional CVP-guided regimen in studies on renal transplant recipients. [26][27][28] De Cassai et al used PPV to guide fluid management to achieve adequate urine output and found it to be as effective as liberal fluid therapy.…”

“… 6 Literature on GDFT in the neurosurgical population is limited with contradictory results. 11 12 13 23 24 25 …”

The Effect of Goal-directed Fluid Management based on Stroke Volume Variation on ICU Length of Stay in Elderly Patients Undergoing Elective Craniotomy: A Randomized Controlled Trial

“…A previous study among aneurysmal subarachnoid hemorrhage patients by Bloria et al 27 also reported that the implementation of goal-directed fluid therapy could reduce intraoperative fluid intake. Results of this study failed to show a reduction in the ICU length of stay and postoperative complication rates.…”

Central Venous-to-Arterial CO2 Difference–Assisted Goal-Directed Hemodynamic Management During Major Surgery—A Randomized Controlled Trial

“…Trails have shown a benefit of goal-directed fluid therapy on postoperative outcomes in neurosurgical patients. 39 The definition and assessment of organ dysfunction have varied between studies, leading us to adopt the SOFA score, a more pragmatic and widely accepted definition.…”