Acute Cerebrovascular Conditions · European Guidelines · Fluid Management · Haemodynamics · Osmotherapy · Subarachnoid Haemorrhage · Traumatic Brain Injury

Fluid Therapy in Neurointensive Care patients – An ESICM Recommendation

Just published: the European Society of Intensive Care Medicine´s consensus document on fluid administration in the NICU. It covers all manner of neurocritical conditions and sums up the available evidence for various fluid therapy approaches.

As expected there are few recommendations that aren´t already well established and by now fairly uncontroversial (multimodal monitoring, avoiding colloids, not using CVP as volume status endpoint etc.). A few interesting things to highlight, though:

Mannitol and hypertonic saline seem to still be viewed with equipoise with regard to efficacy and safety when there is increasing evidence (admittedly still weak) to support HS as the preferred agent (1,2,3,4).

Furthermore, the group operates with an ICP trigger point of 25 mmHg before initiating osmotherapy, whereas many clinicians would be reluctant to let patients rise much above 20 mmHg. Exact ICP-thresholds for osmotherapy are obviously patient-specific and can probably never be empirically ascertained with any degree of certainty, but it is contraintuitive for many neurointensivists to let it rise to those levels for any length of time.

This document is very well developed, with obvious scientific rigour behind it. It´s an important publication that should be read by all neurointensivists. However, with the often weak evidence surrounding the various aspects of fluid therapy, it´s hardly surprising that the group is unable to produce many new and solid recommendations.

  1. Kerwin AJ, Schinco MA, Tepas JJ, 3rd, Renfro WH, Vitarbo EA, Muehlberger M:The use of 23.4% hypertonic saline for the management of elevated intracranial pressure in patients with severe traumatic brain injury: a pilot study. J Trauma 2009, 67:277-282.
  2. Mortazavi MM, Romeo AK, Deep A, Griessenauer CJ, Shoja MM, Tubbs RS, Fisher W: Hypertonic saline for treating raised intracranial pressure: literature review with meta-analysis. J Neurosurg 2012, 116:210-221.
  3. Kamel H, Navi BB, Nakagawa K, Hemphill JC, 3rd, Ko NU: Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med 2011, 39:554-559.

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