Table 1 Summary of guideline/consensus conference recommendations on routine fluid and circulatory volume management in brain-injured patients

AHA/ASA SAH guidelines (2012) [7]

1. Monitoring volume status in certain patients with recent aneurysmal SAH by some combination of central venous pressure, pulmonary wedge pressure and fluid balance is reasonable, as is treatment of volume contraction with crystalloid or colloid fluids. (Class IIa, evidence level B)

1. Maintenance of euvolemia and normal circulating blood volume is recommended to prevent DCI. (Class I, evidence level B)

2. Prophylactic hypervolemia […] before the development of angiographic spasms is not recommended. (Class III, evidence level B)

3. Administration of large volumes of hypotonic fluids and intravascular volume contraction is not recommended. (Class III, evidence level B)

Neurocritical Care Society recommendations on critical care management in SAH (2011) [6]

1. Monitoring of volume status may be beneficial. (Moderate quality evidence; weak recommendation)

2. Vigilant fluid balance management should be the foundation for monitoring intravascular volume status. While both non-invasive and invasive monitoring technologies are available, no specific modality can be recommended over clinical assessment. (Moderate quality evidence; weak recommendation)

3. Central venous lines should not be placed solely to obtain CVP measures and fluid management based solely on CVP measurements is not recommended. (Moderate quality evidence; strong recommendation)

4. Use of PACs incurs risk and lacks evidence of benefit. Routine use of PACs is not recommended. (Moderate quality evidence; strong recommendation)

1. Intravascular volume management should target euvolemia and avoid prophylactic hypervolemic therapy. In contrast, there is evidence for harm from aggressive administration of fluid aimed at achieving hypervolemia. (High quality evidence; strong recommendation)

2. Isotonic crystalloid is the preferred agent for volume replacement. (Moderate quality evidence; weak recommendation)

3. In patients with a persistent negative fluid balance, use of fludrocortisone or hydrocortisone may be considered. (Moderate quality evidence; weak recommendation)

Consensus statement on multi-modality monitoring in neurocritical care (2014) [19]

1. We recommend that hemodynamic monitoring be used to establish goals that take into account cerebral blood flow (CBF) and oxygenation. These goals vary depending on diagnosis and disease stage. (Strong recommendation, moderate quality of evidence)

2. We recommend the use of additional haemodynamic monitoring (e.g. intravascular volume assessment, echocardiography, cardiac output monitors) in selected patients with haemodynamic instability. (Strong recommendation, moderate quality of evidence)

3. We suggest that the choice of technique for assessing pre-load, after-load, cardiac output and global systemic perfusion should be guided by specific evidence and local expertise. (Weak recommendation, moderate quality of evidence)

Not applicable

Brain Trauma Foundation guidelines on traumatic brain injury (2007) [22]

No recommendations

No recommendations

AHA/ASA guidelines for the early management of patients with acute ischaemic stroke (2013) [20]

No recommendations

1. Daily fluid maintenance for adults estimated as 30 ml/kg body weight

2. Use isotonic fluids rather than hypotonic fluids (might exacerbate ischaemic brain oedema)

3. Hypovolemia should be corrected with i.v. normal saline

AHA/ASA Recommendations for the management of cerebral and cerebellar infarction with swelling [21]

No recommendations

1. Use of adequate fluid administration with isotonic fluids might be considered. (Class IIb, evidence level C)

2. Hypotonic or hypo-osmolar fluids are not recommended. (Class III, evidence level C)