Randomized, Double-Blind Trial of the Effect of Fluid Composition on Electrolyte, Acid–Base, and Fluid Homeostasis in Patients Early After Subarachnoid Hemorrhage

Abstract

Background Hyper-and hyponatremia are frequently observed in patients after subarachnoidal hemorrhage, and are potentially related to worse outcome. We hypothesized that the fluid regimen in these patients is associated with distinct changes in serum electrolytes, acid-base disturbances, and fluid balance. Methods Thirty-six consecutive patients with SAH were randomized double-blinded to either normal saline and hydroxyethyl starch dissolved in normal saline (Voluven Ò ; saline) or balanced crystalloid and colloid solutions (Ringerfundin Ò and Tetraspan Ò ; balanced, n = 18, each) for 48 h. Laboratory samples and fluid balance were evaluated at baseline and at 24 and 48 h. Results Age [57 ± 13 years (mean ± SD; saline) vs. Conclusions Treatment with saline-based fluids resulted in a greater number of patients with hyperchloremia, hyperosmolality, and positive fluid balance >1,500 mL early after SAH, while administration of balanced solutions did not cause more frequent hyponatremia or hypo-osmolality. These results should be confirmed in larger studies.

Positive Fluid Balance Is Associated With Poor Outcomes in Subarachnoid Hemorrhage

“…A positive fluid balance could make patients more susceptible to cerebral edema or cortical spreading depression by affecting electrolyte homeostasis. 36 Hematologic, renal, and hepatic dysfunction in aSAH could also be influenced by a positive fluid balance. 20,37 Given the consistency of the association on multivariable analyses, even after adjusting with propensity scores, we think that the relationship of positive fluid balance with functional outcome is not related to greater fluid administration in worse cases.…”

Hyponatremia Is an Independent Predictor of In-Hospital Mortality in Spontaneous Intracerebral Hemorrhage

“…For neurointensive care patients, only few studies are available focussing on postoperative neurosurgical patients, traumatic brain injury, and subarachnoid hemorrhage supporting the associations of hyponatremia with increased mortality, longer hospital stay, and raised complications. [6][7][8][9] Pathophysiological mechanisms that link hyponatremia to outcome in neurointensive care include the development of cerebral edema, seizures, and delayed cerebral infarctions. In these patients, hyponatremia may be caused by the syndrome of inappropriate antidiuretic hormone secretion and cerebral salt wasting syndrome.…”

Cristaloides y coloides en la reanimación del paciente crítico

“…En un ensayo aleatorizado y doble ciego realizado en 40 pacientes con traumatismo craneoencefálico grave (GCS ≤ 8 puntos) o hemorragia subaracnoidea (WFNS ≥ 3), la incidencia de acidosis hiperclorémica (objetivo primario) fue significativamente menor con el empleo de una solución balanceada que con el uso de suero salino, aunque sin diferencias en la existencia de hipertensión intracraneal o mortalidad 45 . Del mismo modo, en un ensayo clínico aleatorizado y doble ciego realizado en pacientes con hemorragia subaracnoidea, el empleo de una solución balanceada se asoció a una menor incidencia de acidosis hiperclorémica, pero sin aparición de hiponatremia o hipoosmolaridad, que podrían conllevar consecuencias negativas en este tipo de pacientes 46 .…”