Optimizing hemodynamics in the clinical setting

Abstract

Hypotension is common following traumatic brain injury and can contribute to a poor outcome. Hypovolemia is the most common cause of hypotension in this setting, but myocardial dysfunction may also occur. Fluid resuscitation is the initial step in treating hypotension. Recent trials have failed to demonstrate an advantage of colloids or hypertonic saline over normal saline resuscitation, and albumin resuscitation was even associated with a higher mortality rate. Therefore normal saline remains the standard resuscitation fluid, even though colloids and hypertonic saline have some theoretical advantages following brain injury. The optimal hemoglobin concentration for the brain-injured patient remains controversial, and the decision to transfuse remains an assessment of the risk-benefit ratio of improving cerebral oxygen delivery with the risk of complications of transfusions. When blood pressure remains inadequate following fluid resuscitation, vasopressors may be needed. While definitive studies are lacking, available studies suggest that norepinephrine and phenylephrine have advantages over dopamine as the initial choice for vasopressor.