title: Early intensive versus minimally invasive approach to postoperative hemodynamic management after subarachnoid hemorrhage.
abstract: OBJECTIVE
  The results of previous studies suggest that early goal-directed fluid therapy (EGDT) reduces delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage, but the effects of EGDT on clinical outcomes are still unclear. This study aimed to determine whether EGDT improves outcomes compared with standard less-invasive hemodynamic therapy.
  
  
  METHODS
  This study included 160 patients treated within 24 hours after subarachnoid hemorrhage, randomized to receive either (1) EGDT guided by preload volume and cardiac output monitored by transpulmonary thermodilution (treatment group) or (2) standard therapy guided by fluid balance or central venous pressure, assisted by uncalibrated less-invasive cardiac output monitoring during hyperdynamic therapy in patients with clinical or radiological indications of DCI (control group). DCI determined by clinical or radiological findings and functional outcome determined by the modified Rankin Scale score at 3 months were compared between groups.
  
  
  RESULTS
  For all clinical grades combined, there were no significant differences in the rates of DCI (33% versus 42%; P=0.33) or modified Rankin Scale score of 0 to 3 at 3 months (67% versus 57%; P=0.22) between the 2 groups. For patients with poor clinical grade, those who received EGDT had a significantly lower rate of DCI (5% versus 14%; P=0.036), modified Rankin Scale score of 0 to 3 at 3 months (52% versus 36%; P=0.026), and shorter length of intensive care unit stay (14 versus 17 days; P=0.043) than those who received standard therapy.
  
  
  CONCLUSIONS
  EGDT is beneficial for reducing DCI and improving postoperative functional outcome in patients with poor clinical grade.
  
  
  BACKGROUND
  http://www.clinicaltrials.gov. Unique identifier: UMIN000007509.
authors.affiliation: From the Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan (T.M., A.S., T.I.); Department of Neurosurgery, Teine Keijinkai Hospital, Sapporo, Japan (K.K.); Department of Nuclear Medicine and Radiology, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan (T.M., Y.T.); and Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan (K.K., S.T.).
authors.forename: Tatsushi
authors.initials: T
authors.lastname: Mutoh
authors.forename: Ken
authors.initials: K
authors.lastname: Kazumata
authors.forename: Shunsuke
authors.initials: S
authors.lastname: Terasaka
authors.forename: Yasuyuki
authors.initials: Y
authors.lastname: Taki
authors.forename: Akifumi
authors.initials: A
authors.lastname: Suzuki
authors.forename: Tatsuya
authors.initials: T
authors.lastname: Ishikawa
mesh_terms: D061605:Administration, Intravenous; D000368:Aged; D002545:Brain Ischemia / Q000188:drug therapy / Q000209:etiology / Q000517:prevention & control*; D002302:Cardiac Output / Q000502:physiology; D002496:Central Venous Pressure / Q000502:physiology; D019468:Disease Management; D042241:Early Diagnosis; D005260:Female; D005440:Fluid Therapy / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000295:instrumentation / Q000379:methods*; D011184:Postoperative Period; D012720:Severity of Illness Index; D013345:Subarachnoid Hemorrhage / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome
keywords: delayed cerebral ischemia; fluid therapy; hemodynamic management; subarachnoid hemorrhage