Induced hypertension, hypervolemia and hemodilution (triple-H) therapy has historically been considered to be beneficial for the treatment of vasospasm in patients with non-traumatic subarachnoid hemorrhage (SAH). In the October issue of Neurocritical Care, Martini and colleagues from the Oregon Health and Science University and University of Washington sought to determine the association between early fluid balance and outcomes for patients with SAH.

They reviewed 356 patients with SAH in a retrospective trial at a level I trauma and stroke referral center in Seattle, Washington. Traumatic and nonaneuyrsmal SAH patients were excluded. Two groups were examined: a positive fluid balance group (n=221) and a negative fluid balance group (n=135). The patients in the positive fluid balance group had a positive fluid balance by intensive care unit day 3; those in the negative fluid balance group had a zero or negative cumulative fluid balance. All patients were managed with daily transcranial Doppler exams (TCD) according to an institutional fluid protocol for managing SAH. Adjusted and unadjusted regression models were used to assess the relationship of various known confounders and outcomes of interest.

SAH patients with a positive fluid balance were more likely to have a lower Glasgow Coma Scale score (8.7 vs. 10.0, P<0.01) and higher score on Simplified Acute Physiology Score II (39.6 vs. 31.9, P<0.01). Positive fluid balance patients also required statistically significantly more vasopressor use, more fludrocortisone use and more blood product use. In a model adjusting for variables such as age, Hunt-Hess score, Fisher grade, troponin elevation, and respiratory failure, patients with a positive fluid balance were more likely to have a longer length of stay (odds ratio [OR] 1.26; 95% confidence interval [CI], 1.05-1.51, P value not provided), but were not more likely to die in the hospital or suffer a new stroke. Patients with a positive fluid balance had a significantly higher degree of vasospasm (OR 2.25, 95% CI, 1.37-3.71) as detected by TCD exams.

This study adds to a growing body of evidence that has shown the “hypervolemia” arm of triple-H therapy to be of limited utility, and possibly harmful, for patients with vasospasm from SAH.  As an observational trial, this study has several limitations. Although an institutional protocol was used, the authors did not report compliance with this protocol or additional co-interventions. Individual practice patterns were not described, follow-up was not complete (not all patients had TCD exams), and TCD exams, not angiography, were used to confirm vasospasm. The authors’ conclusions remained guarded in view of these limitations, but based on the findings from this study, intensive care management of SAH patients should include careful intravenous fluid management (perhaps tailored to individual patient needs), keeping in mind the deleterious effects associated with the accumulation of a positive fluid balance.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO, PhD. Each installment highlights journal articles most relevant to the critical care practitioner.