Supplemental Digital Content
Optimal range of global end-diastolic volume for fluid management after
aneurysmal subarachnoid hemorrhage: A multicenter prospective cohort study
Takashi Tagami MD, PhD1, 2, *; Kentaro Kuwamoto MD3,*; Akihiro Watanabe MD, PhD1;
Kyoko Unemoto MD, PhD3; Shoji Yokobori MD, PhD1; Gaku Matsumoto MD1;
Hiroyuki Yokota MD, PhD1; on behalf of SAH PiCCO Study Group
1
Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo,
Japan
2
School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo,
Japan
3
Department of Emergency and Critical Care Medicine, Nippon Medical School
Tamanagayama Hospital, Tokyo, Japan
*These authors contributed equally to this work.
Contents:
Supplemental Methods
Supplemental References
Supplemental Figure Legends
Supplemental methods
The PiCCO® monitoring system (Pulsion Medical Systems, Munich, Germany) uses the
single-thermal indicator technique to calculate cardiac output (CO), global end-diastolic
volume (GEDV), extravascular lung water (EVLW), and other volumetric parameters (1).
After insertion of the central venous catheter, the tip was placed near the right atrium
and a thermistor-tipped arterial catheter, the PiCCO® catheter, was inserted into the femoral
artery and connected to the PiCCO® monitoring system. A 15–20 mL bolus of cold (<8°C),
normal saline was injected through the central venous catheter. The thermodilution curves
were then recorded by the thermistor at the tip of the PiCCO® catheter to allow for estimation
of the CO using the Stewart–Hamilton method (1). Concurrently, the mean transit time and
the exponential downslope time of the transpulmonary thermodilution curve were calculated.
The product of CO and mean transit time represents the intrathoracic thermal volume (ITTV)
(2). The product of CO and exponential downslope time is the pulmonary thermal volume
(PTV). GEDV is calculated as the difference between the ITTV and PTV which represents
the combined end-diastolic volumes of the 4 cardiac chambers. This allows the calculation of
intrathoracic blood volume (ITBV) from its linear relationship with GEDV: ITBV = [1.25 ×
GEDV] – 28.4 (2). EVLW is the difference between the ITTV and the ITBV. Previous
studies have also shown that the precision of the variables are clinically acceptable (3, 4). The
use of the PiCCO catheter does not increase the risk of complications when compared to the
commonly used short peripheral arterial or pulmonary artery catheters (5).
The GEDV were indexed to the body surface area (GEDI, normal range 680–800
mL/m2) (1). The GEDI behaves as an indicator of cardiac preload, which may represent the
intravascular volume (6). Hemodynamic management using GEDI reduces the need for
vasopressors during cardiac surgery, when compared to central venous pressure
(CVP)-directed management (7). It provides better volume management when a therapeutic
algorithm including GEDI is used in necrotizing pancreatitis (8). GEDI has also played an
important role in the hemodynamic management of several kinds of disease states, including
burn (9), post-cardiac arrest syndrome (10), and SAH (11).However, a recent meta-analysis
suggested a need for defining different therapeutic targets for different patient
populations(12). To date, there is no GEDI threshold value that predicts the complications
after SAH.
EVLW was indexed to the predictive body weight (ELWI), calculated as follows:
men, predictive body weight (kg) = 50 + 0.91 × (height in centimeters − 152.4); women,
predictive body weight (kg) = 45.5 + 0.91× (height in centimeters − 152.4] (13-15). The
accuracy of transpulmonary thermodilution EVLW has been validated when compared to
quantitative CT scan (16) and gravimetry, which is considered to be the gold standard.(17-20)
The normal ELWI value has previously been shown to be approximately 7.4 ± 3.3
mL/kg (19). ELWI > 10 mL/kg is regarded as increased EVLW in several clinical studies
(20-25). Recent studies proposed that an ELWI > 10 ml/kg is an ideal value to include in the
future definition of acute respiratory distressed syndrome (22-24, 26). In addition, ELWI > 14
mL/kg is regarded as severe pulmonary edema which represent a level of severity previously
shown to influence prognosis and mortality reported in both clinical and pathological studies
(24, 27, 28).
Supplemental References
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Supplemental figure Legends
Figure S1. Frequency of distribution for patients who developed delayed cerebral ischemia
measured in the 4 phases (Phase 1: PBD 1–3; Phase 2: PBD 4–7; Phase 3: PBD 8–10; and
Phase 4: PBD 11–14).
Figure S2. Frequency of distribution for patients who developed severe pulmonary edema
measured in the 4 phases (Phase 1: PBD 1–3; Phase 2: PBD 4–7; Phase 3: PBD 8–10; and
Phase 4: PBD 11–14).
Figure S3: Receiver operating characteristic analysis that associated with delayed cerebral
ischemia.
Figure S4: Receiver operating characteristic analysis that associated with occurrence of
severe pulmonary edema.