The challenges of hypervolemic therapy in patients after subarachnoid haemorrhage

Abstract

Purpose: The triple-H therapy is widely used for cerebral vasospasm (CV) prevention and treatment in patients after subarachnoid haemorrhage (SAH). However, this practice is based on low level evidence. Aim of this study was to evaluate errors in fluid administration, fluid balance monitoring and bedside charts completeness during a trial of triple-H therapy.

Materials and methods: An audit of the SAH patient charts was performed. A total of 508 fluid measurements were performed in 41 patients (6 with delayed cerebral ischaemia; DCI) during 14 days of observation.

Results: Underestimating for intravenous drugs was the most frequent error (80.6%; 112), resulting in a false positive fluid balance in 2.4% of estimations. In 38.6% of the negative fluid balance cases, the physicians did not order additional fluids for the next 24h. In spite of that, the fluid intake was significantly increased after DCI diagnosis. The mean and median intake values were 3.5 and 3.8l/24h respectively, although 40% of the fluid balances were negative. The positive to negative fluid balance ratio was decreasing in the course of the 14 day observation.

Conclusions: This study revealed inconsistencies in the fluid orders as well as mistakes in the fluid monitoring, which illustrates the difficulties of fluid therapy and reinforces the need for strong evidence-based guidelines for hypervolemic therapy in SAH.

Keywords: Aneurysmal subarachnoid haemorrhage; Delayed cerebral ischaemia; Intracranial vasospasm; Recommendations adherence; Triple-H therapy.