|Year : 2019 | Volume
| Issue : 1 | Page : 15-18
Fluid administration strategies in traumatic brain injury
Abdulrahman Alharthy1, Waleed Tharwat Aletreby1, Ibrahim Soliman1, Fahad AlFaqihi1, Waseem Alzayer1, Nassir Nasim Mahmoud1, Lawrence Marshall Gillman2, Dimitrios Karakitsos3
1 Department of Critical Care, Neurocritical Care Unit, King Saud Medical City, Riyadh, KSA
2 Department of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, MB, Canada
3 Department of Critical Care, Neurocritical Care Unit, King Saud Medical City, Riyadh, KSA; Department of Critical Care, Keck School of Medicine, USC, LA, CA, USA
|Date of Web Publication||30-May-2019|
Department of Critical Care, Neurocritical Care Unit, King Saud Medical City, Riyadh
Source of Support: None, Conflict of Interest: None
Fluid restriction strategies may reduce morbidity and mortality in critical care patients and are currently trending as preliminary data showed encouraging results. A positive fluid balance was related to increase morbidity and mortality in a variety of disorders (i.e., sepsis, acute respiratory distress syndrome, and postsurgical cases) as well as resulted in an increased rate of complications observed in the intensive care unit setting. Traumatic brain injury (TBI) has been managed thus far in terms of fluid resuscitation under the concept of general trauma resuscitation recommendations that favored euvolemia above all fluid balance states. Notwithstanding, scarce data exist to clarify details about fluid management strategies in TBI such as the desirable fluid balance per se and/or its impact on patients' outcomes. We, therefore, reviewed previously published data and concluded in an observational manner (by creating a visual display model) that a highly positive and/or a negative fluid balance may have a detrimental impact on the prognosis of TBI patients. Accordingly, well-designed randomized controlled trials are clearly required to investigate further and in detail the most efficacious fluid administration strategies in TBI contributing thus in the rapidly expanding field of neurocritical care.
Keywords: Fluid balance, randomized controlled trials, traumatic brain injury
|How to cite this article:|
Alharthy A, Aletreby WT, Soliman I, AlFaqihi F, Alzayer W, Mahmoud NN, Gillman LM, Karakitsos D. Fluid administration strategies in traumatic brain injury. Saudi Crit Care J 2019;3:15-8
|How to cite this URL:|
Alharthy A, Aletreby WT, Soliman I, AlFaqihi F, Alzayer W, Mahmoud NN, Gillman LM, Karakitsos D. Fluid administration strategies in traumatic brain injury. Saudi Crit Care J [serial online] 2019 [cited 2020 Jun 6];3:15-8. Available from: http://www.sccj-sa.org/text.asp?2019/3/1/15/259472
| Introduction|| |
Traumatic brain injury (TBI) is one of the major causes of mortality and disability worldwide. In the United Kingdom, the incidence of TBI is 1.4 million cases per year with the majority being mild. The World Health Organization predicts increased rates of TBI by 2020. The burden of TBI on health-care systems in terms of the utilization of resources and on the community in terms of social functionality of TBI victims remains a major challenge. The sheer magnitude of the health-care issue imposed by TBI has led to the development of several management protocols such as the brain trauma foundation guidelines among others.
The aforementioned guidelines include versatile and detailed aspects of TBI management; however, when it comes to fluid balance data appear to be incomplete. Most TBI guidelines recommend euvolemia using isotonic fluids although no specific recommendations on the amount of fluids to be administered or total fluid balance to be achieved exist thus far. Notwithstanding, the positive fluid balance was related to detrimental effects on mortality, mechanical ventilation days, and lung function in critical care patients. Volume overloading was reported as an independent prognostic factor of mortality in critically ill sepsis patients. The former was associated with increased mortality risk even after adjustment for chronic medical conditions and different severity markers of illness at the time of intensive care unit (ICU) discharge. In contrast, the achievement of a negative fluid balance in surgical critically ill patients was associated with mortality reduction. Whether a comparable to the aforementioned fluid strategy trend might be the case in TBI management remains unclear. Hence, the aim of this review was to examine the available body of evidence regarding the impact of fluid balance on TBI outcomes.
| Pathophysiological Considerations|| |
Fluid balance management in TBI aims on restoring intravascular volume and stabilizing hemodynamics to ensure adequate cerebral perfusion pressures (CPPs). The former may be particularly important in TBI as various complex factors play a joining role in determining the effect of fluid volume on cerebral blood flow and cerebral tissue oxygenation such as the disruption of blood–brain barrier (BBB), inflammatory mediators, and cerebral autoregulatory mechanisms. Moreover, TBI patients are prone to intravascular, osmotic, and electrolyte disturbances due to central neuroendocrine disturbances.
Under normal circumstances, fluid shifts across an intact BBB are compensated by the neurons through active solute depletion to the extracellular compartment and the endothelial cells of BBB to expel water to the intravascular compartment. The aforementioned mechanisms are impaired in TBI thus fluid shifts become more dependent on pressure differences between intravascular and extravascular compartments.
Fluid balance could affect CPP in two ways: driving-in and driving-out. The obvious driving-in force is that of the arterial pressure. The driving-out mechanism is attributed mainly to the venous pressure. When the latter is high and/or the arterial pressure is low, CPP could be significantly reduced depending surely on impaired cerebral autoregulation. Normally, high central venous pressure (CVP) should not be reflected on the intracranial venous circuits when the intracranial venous structures are collapsed due to a higher intracranial pressure (ICP). However, this might be the case when CVP exceeds ICP in mechanically ventilated patients baring an extremely high positive end-expiratory pressure.,
| Methods|| |
This was a nonsystematic electronic literature search integrating articles reporting the impact of fluid balance on TBI outcomes. There were no restrictions imposed on language, age of patients, year of publication, or methodology of the study; however, we excluded studies analyzing solely other causes of brain injury. We searched for relevant articles in PubMed and EMBASE databases. We did not attempt to evaluate the quality or risk of bias of individual studies.
| Results|| |
Our search revealed seven major studies that were included in this review. Notably, only two studies were randomized controlled trials (RCT). None of the aforementioned studies was originally designed to investigate the impact of fluid balance on TBI. Five studies were retrospectively analyzing data of patients' medical records or commenting on data of other studies. [Table 1] summarizes the results of included trials.
The study by Roquilly et al., 2013, recruited both TBI and subarachnoid hemorrhage mechanically ventilated patients, who were randomized to either isotonic balanced solution or isotonic sodium chloride for 48 hrs reported neither differences in fluid status between the two groups nor difference in ICU mortality and length of ICU stay.
Ichai et al., 2013, conducted an RCT on 60 TBI patients integrating ICP monitoring which were randomized to receive half molar lactated ringer versus saline at a rate of 0.5 ml/kg/h for 48 h. The saline group had significantly higher 48 h fluid balance in ml/kg (27 [11–43] vs. 5 [−5–19], P < 0.01). The former group exhibited more episodes of high ICP; however, poor neurological outcome (death, vegetative state, or severe disability) was not different at 6 months even though more survivors in the saline group had poorer outcome (P = 0.16).
Clifton et al., 2002, studied the impact of fluid balance on ICP and CPP in a retrospective manner. When the patients were stratified in quartiles of 4 days' fluid balance, poor outcome (death, severe disability, or vegetative state) occurred more frequently in the group with balance <−594 ml followed by the group with balance >4859, while the euvolemic group exhibited better outcomes. None of the aforementioned differences were statistically significant; however, stepwise logistic regression analysis revealed that fluid balance <−594 was significantly associated with poor outcomes (P = 0.005).
Another study by Fletcher et al., 2010, revealed that fluid balance was not a predictor of refractory intracranial hypertension, whereas it was a predictor for the development of pulmonary edema (Hazard Ratio 1.69 [95% confidence interval [CI] 1.4–2.04], P < 0.0001).
The impact of fluid balance on ICP was reported to be significant by Moore et al., 2015, in a retrospective analysis of 100 adult TBI patients. Those with a positive fluid balance between days 3 and 7 had a higher mean ICP (13.9 vs. 12.6 mmHg, P = 0.05), and when adjusted for confounders, a more positive fluid balance in days 3–7 was significantly associated with an increase of mean ICP (P = 0.04).
Similar results were reported by Zhao et al. 2016 in a retrospective analysis of 351 adult patients with moderate-to-severe TBI. Patients at the low (<637 mL) and upper (>3673 mL) tertiles of fluid balance were associated with poor outcomes. More patients in the upper tertile had ICP higher than 20 mmHg (P = 0.009). A fluid balance in the upper tertile was an independent predictor of poor 30 days' clinical outcomes after the adjustment for confounding variables in a multivariable logistic regression model (odds ratio: 1.373 [95% CI 1.003–1.880) P = 0.047].
Finally, in a post hoc analysis derived from the data of TBI and cerebrovascular accident patients who participated in an observational study about the occurrence of sepsis, survivors had a significantly lower mean fluid balance compared to nonsurvivors (−0.2 ± 11.1 vs. 0.1 ± 1.5 l, P < 0.05).
| Discussion|| |
A positive fluid balance observed at different stages of ICU hospitalization was found to be harmful in critically ill patients with sepsis, influenza, cancer as well as in postsurgical cases.,,,, In TBI patients, scarce data exist to support that fluid resuscitation should be directed toward euvolemia by the administration of isotonic fluids. Previously published data suggested that both volume overloading and depletion should be avoided. However, there is still limited evidence that loading brain-injured patients with fluids may exacerbate brain edema formation when the BBB is disrupted; and that hypervolemia may be detrimental as appears to be the case in nonbrain injured patients. Furthermore, evaluating different types of traumatic injuries which may coexist in a TBI patient such as other blunt or penetrating torso and/or extremity trauma is vital especially in acute clinical settings. Therefore, adopting a suitable fluid resuscitation strategy to achieve desirable hemodynamic targets should be individualized for each patient as it remains largely a multifactorial clinical decision.
Studies evaluating the impact of fluid balance on TBI outcomes are scarce. Most published studies are retrospective and/or observational and thus not designed to evaluate the aforementioned endpoint per se the latter seems to be the case for RCTs that are originally designed and powered for a different outcome. Hence, no safe conclusions can be drawn regarding the impact of fluid balance on TBI outcomes that are free of confounders and/or attributed solely to that factor. Notwithstanding, the studies that were analyzed in this review suggested that poor outcomes in TBI patients, namely death, severe disability, or vegetative state, were mainly observed when positive and/or negative fluid balance occurred while euvolemia was associated with better prognosis. This observation when visually displayed could be tailored as a curve baring one end (positive fluid balance) higher than the other one (negative fluid balance) while the area in the middle of the curve (low incidence of poor TBI outcomes) represents euvolemic states. Moreover, published data revealed that as the fluid balance increased so did the rate of various complications such as high ICP, pulmonary edema, and acute respiratory distress syndrome in a linear manner which can be further superimposed on the aforementioned curve as an inclined straight line creating thus a “gondola-like” visual display model. Analyzing further the latter is beyond the scopes of the current review.
Our study has several limitations which are mainly attributed to its inherent nature. There was no statistical analysis or estimation of the overall effect of the pooled data from included studies as the latter were scarce. However, we managed to tailor a visual display model that underpins the effect of fluid balance on TBI based on previously published data. The aforementioned model illustrates that volume overloading is associated with a poor prognosis and increased rate of complications in TBI. Adequately powered RCTs specifically designed to study the impact of fluid balance on TBI outcomes while controlling for other factors are required. Further research studies could shed more light to previous observations and hopefully establish “cut-off” values for the administration of fluids in the management of TBI.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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