Fluid Management in Traumatic Brain Injury

Abstract

The major goal of perioperative and critical care management of traumatic brain injury patients is to prevent secondary injury. Understanding the various choices for fluid management in the prehospital and preoperative stages is essential in minimizing secondary injury to the brain and providing optimal care to patients with traumatic brain injury. Adequate fluid resuscitation is focused on maintaining cerebral perfusion pressure and oxygen delivery to the brain. The major types of resuscitative fluids are crystalloids, colloids, and blood products. Balanced crystalloids such as plasma-lyte and lactated ringers are relatively hypotonic and carry a theoretical risk for worsening cerebral edema. Given these factors, normal saline is the preferred IV fluid for management of the TBI patient. Regarding red blood cell transfusion, the classic approach has been to transfuse red blood cells (RBCs) in patients with TBI to maintain a hemoglobin (Hb) level greater than 10 g/dl or hematocrit greater than 30% for the theoretical principle of maintaining optimal oxygen-carrying capacity. However, more recently, clinical practice has moved toward a restrictive transfusion strategy (maintaining Hb concentrations ≥7 g/dl) after studies showed liberal transfusion strategies (Hb ≥10 g/dl) may be unnecessary or perhaps even harmful in the general critical care setting. Hyperosmolar therapy is a common tool in the armamentarium used to manage raised ICP. There is little consensus regarding the exact agent, administration (bolus vs infusion), and timing/duration of administration. Commonly used options for hyperosmolar agents include mannitol and hypertonic saline. This chapter highlights the current recommendations in the fluid management of patients with traumatic brain injury.