FLUID MANAGEMENT IN

NEUROLOGY &
NEUROCRITICAL CARE
Dr Nagesh Jadav

IMPORTANT PRICIPLES

Secondary Brain Injury

Delayed

Cerebral Ischemia

Cerebralhypoxia
Hypotension
Cerebral

edema

Raisedintracranial

pressure

Other direct to indirect complication

Hypercapnoea
Acidosis

Impaired

Cerebral Autoregulation

QUICK SUMMARY
GIVING

THE RIGHT FLUID AND RIGHT

AMOUNT TO RIGHT PATIENT
In line with the consensus statement on
multimodality monitoring in neurocritical
care the goal of fluid management is
optimization of cerebral perfusion and
oxygenation and minimizing secondary brain
insults.

FUNDAMENTAL PRINCIPLES:
Skull is a rigid cranial
vault, fixed volume.

CBF = CPP / CVR

20% CO
Jugular
CVP

CPP

BRAIN

Carotid
MAP

CPP = MAP - CVP

CPP = MAP - ICP

FUNDAMENTAL PRINCIPLES

Poiseuille's law: At a constant driving pressure the

flow rate of liquid through a capillary tube is directly
proportional to the fourth power of the radius of the tube
and inversely proportional to the length and viscosity of
the tube

FUNDAMENTAL PRINCIPLES

Cerebral Hemodynamics & ICP Triphasic

Response

First 12hrs - Global blood flow is reduced (Severity

dependent)

12-24hrs - CBF increases, often described as hyperemia

Apart from any intracranial hematoma, elevation of ICP is

due to cytotoxic edema

From 2nd day elevation of CBF and blood volume makes the
vascular engorgement and important contributor of raised
ICP

2nd- 5th Day: CBF again begins to falls several days after
injury

BBB becomes leaky between 2nd-5th day and vasogenic edema

results in raised ICP

CBF & AUTO REGULATION

PATHOPHYSIOLOGICAL
CONSIDERATION
Tonicity: Osmolality of plasma and brain
interstitial fluid and CSF are equal under normal
circumstances
Cerebral oedema is stratified depending on
location (intracellular or extracellular) and BBB
disruption.
Autoregulation concerns the capacity of the blood
vessels in the brain to sustain CBF by
vasodilation or vasoconstriction over a wide range
of systemic blood pressures,
Venous outflow impedance

IV FLUIDS

Crytalloids Vs Colloids
In Neurosurgical patients, use of isotonic iso-osmolar
fluids are recommended. Eg 0.9%Saline
Unfortunately the anecdote and derived principles
from the post hoc analysis that Albumin causes
increased mortality in multi-trauma, prevent the use
of albumin in neurosurgical patients.
Risk of resultant effect of worsening cerebral edema,
from hypertonic fluids infusion such as albumin

GUIDELINE RECOMENDATIONS

None for neurology and neurosurgical patients

BTF has non recommendation to choice of IV Fluid
and just emphasizes for Mx of CPP
SAH Triple H therapy has phased out and the only
component of Permissive HTN has some evidence
among all the components
Crit Care 2010; 14(1) R23

Hypervolemia has shown no good outcomes

Muench E, Horn P, Bauhuf C, Roth H, Philipps M, Hermann

P, et al. Effects of hypervolemia and hypertension on regional
cerebral blood flow, intracranial pressure, and brain tissue
oxygenation after subarachnoid hemorrhage.
Crit Care Med. 2007;35(8):184451. quiz 1852.

MY PRACTICE

Use of simple 0.9% saline for fluid resuscitation

in all neurosurgical patients and probably add
electrolytes with the view that this subset of
patients are at risk of electrolyte abnormalities
I would in general sense not prefer to use
albumin unless patients is has hepatic enc
I have non suggestions for buffered crystalloids