Fluid therapy in the acute brain injured patient

Adequate fluid therapy in the acute brain injured (ABI) patient is essential for maintaining an adequate brain and systemic physiology and preventing intra- and extracranial complications. The target of euvolemia, implying avoidance of both hypovolemia and fluid overloading (or "hypervolemia," by definition associated with fluid extravasation leading to tissue edema) is of key importance. Primary brain injury can be aggravated by secondary brain injury and systemic deterioration through diverse pathways which can challenge appropriate fluid management, e.g. neuroendocrine and electrolyte disorders, stress cardiomyopathy (also known as cardiac stunning) and neurogenic pulmonary edema. This is an updated expert opinion aiming to provide a practical overview on fluid therapy in the ABI patient, partly based on more recent work and stressing the fact that intravenous fluids should be regarded as drugs, with their inherent potential for both benefit and (unintended) harm.

Abstract WMP2: The Path from Research to Successful Implementation in Clinical Practice: Endovascular Treatment in the Netherlands

Introduction: In the Netherlands, acute endovascular treatment (EVT) for ischemic stroke was not reimbursed andonly allowed as rescue treatment according to national guidelines until 2016. We describe the trend in use of EVT before, during and after the pivotal thrombectomy trials.

Methods: Our study used data from all patients who were treated with EVT in the Netherlands from Jan 2002 until Jun 2016 in the Pretrial Registry, MR CLEAN trial and the ongoing MR CLEAN registry. We undertook a time-series analysis to examine trends in the use of EVT using a mixed-effects Poisson regression analysis and several observation plots. Rate ratios (RR) per quarter and 95% confidence intervals (95% CI) were obtained to demonstrate the impact and implementation after the publication of the trial. Regional plots were adjusted for exposure time and population density.

Results: Between 2004 and 2010, 491 patients were treated with EVT in the Netherlands. In 2010, the MR CLEAN trial started. All hospitals providing EVT in the Netherlands included patients and reimbursement was conditional on participation in MR CLEAN. At first, a non-significant increase in EVT-treated patients was observed (RR: 4.6 [95%CI 0.1-9.1]). In 2015, an immediate steep increase in EVT-treated patients (RR: 20.9 [95%CI 5.5-30.1]) (Fig. 1) and a more even spread over the country was observed (Fig. 2). In the first years after the trial, 33% of the patients who were considered to be eligible for EVT were treated with EVT.

Conclusion: A strict national policy regarding evidence based treatments can be successful. Ongoing efforts are directed at further increasing the proportion of stroke patients with EVT.