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\pard\sb0\sl-240{\bkmkstart Pg1}{\bkmkend Pg1}\par\pard\ql \li3479\sb0\sl-200\sl
mult0 \par\pard\ql\li3479\sb0\sl-200\slmult0 \par\pard\ql\li3479\sb0\sl-200\slmu
lt0 \par\pard\ql\li3479\sb0\sl-200\slmult0 \par\pard\ql\li3479\sb0\sl-200\slmult
0 \par\pard\ql\li3479\sb0\sl-200\slmult0 \par\pard\ql\li3479\sb0\sl-200\slmult0
\par\pard\ql\li3479\sb0\sl-200\slmult0 \par\pard\ql\li3479\ri3269\sb74\sl-200\sl
mult0\tx3721 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf3\f4\fs16 Anesthesi
ology Clin N Am \line\tab \up0 \expndtw-3\charscalex100 20 \up0 \expndtw-1\chars
calex100 (2002)329 - 346 \par\pard\ql \li1902\sb0\sl-391\slmult0 \par\pard\ql\li
1902\sb12\sl-391\slmult0 \up0 \expndtw0\charscalex96 \ul0\nosupersub\cf1\f2\fs33
Fluids and the neurosurgical patient \par\pard\ql \li2764\sb105\sl-299\slmult0
\up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf2\f3\fs26 Concezione Tommasino,
MD* \par\pard\ql \li2140\sb76\sl-184\slmult0 \up0 \expndtw-3\charscalex100 \ul0\
nosupersub\cf3\f4\fs16 Institute of Anesthesiology and Intensive Care, Universit
y of Milano, \par\pard\ql \li1646\ri1435\sb3\sl-200\slmult0\tx3593 \up0 \expndtw
-2\charscalex100 Department of Anesthesia and Intensive Care, San Raffaele Hospi
tal, Via Olgettina, \line\tab \up0 \expndtw-2\charscalex100 6020132, Milano, Ita
ly \par\pard\qj \li1133\ri832\sb227\sl-240\slmult0\fi239 \up0 \expndtw-3\charsca
lex100 \ul0\nosupersub\cf4\f5\fs20 The fluid management of neurosurgical patient
s presents special challenges for \up0 \expndtw-1\charscalex100 anesthesiologist

s and intensivists [1]. Neurosurgical patients often receive diu\up0 \expndtw-4\

charscalex100 retics \up0 \expndtw0\charscalex106 (eg, mannitol, furosemide) to
treat cerebral edema and/or to reduce \up0 \expndtw0\charscalex100 intracranial
hypertension. Conversely, they may also require large amounts of \up0 \expndtw-1
\charscalex100 intravenous fluids to correct preoperative dehydration and/or to
maintain intra\up0 \expndtw-1\charscalex100 operative and postoperative hemodyna
mic stability as part of therapy for vaso\up0 \expndtw-3\charscalex100 spasm, fo
r blood replacement, or for resuscitation. \par\pard\qj \li1133\ri892\sb0\sl-240
\slmult0\fi239 \up0 \expndtw-3\charscalex100 For a long time restrictive fluid m
anagement has been the treatment of choice \up0 \expndtw0\charscalex102 in patie
nts with brain pathology, growing from fear that fluid administration \up0 \expn
dtw0\charscalex105 could enhance cerebral edema [2]. It is well known that fluid
restriction, if \up0 \expndtw-2\charscalex100 pursued to excess (hypovolemia),
may result in episodes of hypotension, which \up0 \expndtw-1\charscalex100 can i
ncrease intracranial pressure (ICP) and reduce cerebral perfusion pressure, \up0
\expndtw-2\charscalex100 and the consequences can be devastating [3]. \par\pard
\qj \li1133\ri832\sb0\sl-240\slmult0\fi239 \up0 \expndtw-4\charscalex100 It is u
nfortunate that little substantial human data exist concerning the impact of \li
ne \up0 \expndtw-3\charscalex100 fluids on the brain, or which can guide rationa
l fluid management in neurosurgical \line \up0 \expndtw0\charscalex100 patients.
However, it is possible to examine those factors that influence water \line \up
0 \expndtw-3\charscalex100 movement into the brain, and to make some reasonable
recommendations. \par\pard\qj \li1133\ri891\sb0\sl-240\slmult0\fi239 \up0 \expnd
tw0\charscalex100 This review will address some of the physical determinants of
water move\up0 \expndtw0\charscalex102 ment between the intravascular space and
the central nervous system (CNS). \up0 \expndtw-3\charscalex100 Subsequent secti
ons will address specific clinical situations with suggestions for \up0 \expndtw
-3\charscalex100 the types and volume of fluids to be administered. \par\pard\ql
\li1133\sb0\sl-230\slmult0 \par\pard\ql\li1133\sb0\sl-230\slmult0 \par\pard\ql\
li1133\sb9\sl-230\slmult0 \up0 \expndtw0\charscalex101 Osmolality/osmolarity, os
motic and oncotic pressure, hemodilution \par\pard\qj \li1133\ri892\sb142\sl-240
\slmult0\fi239 \up0 \expndtw-1\charscalex100 With intravenous fluid therapy, thr
ee properties of the blood can be manipu-\line \up0 \expndtw-3\charscalex100 lat
ed: osmolality (owing to concentrations of large and small molecules), colloid \
line \up0 \expndtw-4\charscalex100 oncotic pressure (COP; owing to large molecul
es only), and hematocrit. \par\pard\qj \li1133\sb0\sl-200\slmult0 \par\pard\qj\l
i1133\ri915\sb114\sl-200\slmult0\fi239 \up0 \expndtw-2\charscalex100 \ul0\nosupe
rsub\cf3\f4\fs16 * Department of Anesthesia and Intensive Care, San Raffaele Hos
pital, Via Olgettina, 60 20132, \up0 \expndtw-3\charscalex100 Milano, Italy. \pa
r\pard\ql \li1373\sb14\sl-184\slmult0 \up0 \expndtw-3\charscalex100 E-mail addre
ss: tommasino.concezione@hsr.it (C. Tommasino). \par\pard\qj \li1133\ri1620\sb14
3\sl-200\slmult0 \up0 \expndtw-1\charscalex100 0889-8537/02/$ - see front matter
\ul0\nosupersub\cf5\f6\fs16 D\ul0\nosupersub\cf3\f4\fs16 2002, Elsevier Scienc
e (USA). All rights reserved. \up0 \expndtw-7\charscalex89 PII: S 0 8 8 9 - 8 5
3 7 ( 0 1 ) 0 0 0 1 3 - X \par\pard\sect\sectd\fs24\paperw8640\paperh12960\pard\
sb0\sl-240{\bkmkstart Pg2}{\bkmkend Pg2}\par\pard\li1049\sb0\sl-184\slmult0\par\
pard\li1049\sb0\sl-184\slmult0\par\pard\li1049\sb0\sl-184\slmult0\par\pard\li104
9\sb0\sl-184\slmult0\par\pard\li1049\sb112\sl-184\slmult0\fi0\tx2243 \up0 \expnd
tw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs16 330\tab \up0 \expndtw-1\charscal
ex100 C. Tommasino / Anesthesiology Clin N Am 20 (2002) 329-346\par\pard\ql \li1
049\sb0\sl-230\slmult0 \par\pard\ql\li1049\sb27\sl-230\slmult0 \up0 \expndtw-2\c
harscalex100 \ul0\nosupersub\cf4\f5\fs20 Osmotic pressure \par\pard\qj \li1049\r
i916\sb145\sl-237\slmult0\fi239 \up0 \expndtw-1\charscalex100 This is the hydros
tatic force acting to equalize the concentration of water on \line \up0 \expndtw
-1\charscalex100 both sides of the membrane that is impermeable to substances di
ssolved in that \line \up0 \expndtw-3\charscalex100 water. Water will move along
its concentration gradient. Osmolarity describes the \line \up0 \expndtw-3\char
scalex100 molar number of osmotically active particles per liter of solution. In
practice, the \line \up0 \expndtw0\charscalex102 osmolarity of a solution can b
e \u8216?\u8216?calculated\u8217?\u8217? by adding up the mEq concen-\line \up0

\expndtw0\charscalex105 trations of the various ions in the solution. Osmolality

describes the molar \line \up0 \expndtw0\charscalex102 number of osmotically ac
tive particles per kilogram of solvent. This value is \line \up0 \expndtw-3\char
scalex100 directly \up0 \expndtw0\charscalex104 \u8216?\u8216?measured\u8217?\u8
217? by determining either the freezing point or the vapor \line \up0 \expndtw0\
charscalex102 pressure of the solution. For most dilute salt solutions, osmolali
ty is equal to \line \up0 \expndtw-3\charscalex100 or slightly less than osmolar
ity. \par\pard\ql \li1049\sb0\sl-230\slmult0 \par\pard\ql\li1049\sb19\sl-230\slm
ult0 \up0 \expndtw-3\charscalex100 Colloid oncotic pressure \par\pard\qj \li1049
\ri929\sb142\sl-240\slmult0\fi239 \up0 \expndtw-1\charscalex100 Osmolarity/osmol
ality is determined by the total number of dissolved \u8216?\u8216?par-\line \up
0 \expndtw0\charscalex105 ticles\u8217?\u8217? in a solution, regardless of thei
r size. COP is nothing more that the \line \up0 \expndtw-2\charscalex100 osmotic
pressure generated by large molecules (eg, albumin, hetastarch, dextran). \line
\up0 \expndtw-1\charscalex100 The COP becomes particularly important in biologi
cal systems where vascular \line \up0 \expndtw-1\charscalex100 membranes are oft
en permeable to small ions, but not to large molecules. \par\pard\ql \li1049\sb0
\sl-230\slmult0 \par\pard\ql\li1049\sb0\sl-230\slmult0 \par\pard\ql\li1049\sb29\
sl-230\slmult0 \up0 \expndtw0\charscalex102 Fluid movement between capillaries a
nd tissues \par\pard\qj \li1049\ri975\sb146\sl-235\slmult0\fi239 \up0 \expndtw0\
charscalex103 As defined by the Starling equation [4], the major factors that co
ntrol the \up0 \expndtw-1\charscalex100 movement of fluids between the intravasc
ular and extravascular spaces are the \up0 \expndtw0\charscalex106 transcapillar
y hydrostatic gradient, the osmotic and oncotic gradients, and \up0 \expndtw-1\c
harscalex100 the relative permeability of the capillary membranes that separate
these spaces. \up0 \expndtw-2\charscalex100 The Starling equation is as follows:
\par\pard\ql \li1528\sb190\sl-230\slmult0 \up0 \expndtw0\charscalex100 FM\ul0\n
osupersub\cf6\f7\fs20 \ul0\nosupersub\cf4\f5\fs20 k\ul0\nosupersub\cf6\f7\fs20 \
ul0\nosupersub\cf4\f5\fs20 P\ul0\sub\cf7\f8\fs21 c\ul0\nosupersub\cf6\f7\fs20 \u
l0\nosupersub\cf4\f5\fs20 p\ul0\sub\cf7\f8\fs21 i\ul0\nosupersub\cf4\f5\fs20
P\ul0\sub\cf7\f8\fs21 i\ul0\nosupersub\cf4\f5\fs20
p\ul0\sub\cf7\f8\fs21 c
\ul0\nosupersub\cf6\f7\fs20 \par\pard\qj \li1049\ri975\sb122\sl-240\slmult0 \up0
\expndtw-1\charscalex100 \ul0\nosupersub\cf4\f5\fs20 where FM = fluid movement,
k = the filtration coefficient of the capillary wall \up0 \expndtw-1\charscalex
100 (= how leaky it is), P\ul0\sub\cf8\f9\fs21 c\ul0\nosupersub\cf4\f5\fs20 = h
ydrostatic pressure in the capillaries, P\ul0\sub\cf8\f9\fs21 i\ul0\nosupersub\c
f4\f5\fs20 = hydrostatic \up0 \expndtw-1\charscalex100 pressure (usually negati
ve) in the interstitial space, and p\ul0\sub\cf8\f9\fs21 i\ul0\nosupersub\cf4\f5
\fs20 and p\ul0\sub\cf8\f9\fs21 c\ul0\nosupersub\cf4\f5\fs20 are interstitial
\up0 \expndtw0\charscalex105 and capillary osmotic pressures, respectively. In a
simplified fashion, fluid \up0 \expndtw-3\charscalex100 movement is proportiona
l to the hydrostatic pressure gradient minus the osmotic \up0 \expndtw-3\charsca
lex100 gradient across a vessel wall. The magnitude of the osmotic gradient will
depend \up0 \expndtw-4\charscalex100 on the relative permeability of the membra
ne. \par\pard\qj \li1049\ri962\sb17\sl-220\slmult0\fi239 \up0 \expndtw-2\charsca
lex100 In the periphery (muscle, lung, and other areas), the capillary endotheli
um has \line \dn3 \expndtw0\charscalex105 a pore size of 65 \up2 \expndtw-2\char
scalex100 \u730? \dn3 \expndtw-1\charscalex100 , and is freely permeable to smal
l molecules and ions (Na\ul0\super\cf8\f9\fs21 +\ul0\nosupersub\cf4\f5\fs20 , \p
ar\pard\qj \li1049\ri923\sb28\sl-235\slmult0\fi0 \up0 \expndtw0\charscalex103 Cl
), but not to large molecules, such as proteins [5] (Fig. 1A). Thus, in the \l
ine \up0 \expndtw-2\charscalex100 periphery, movement of water is governed by th
e plasma concentration of large \line \up0 \expndtw-2\charscalex100 molecules (o
ncotic gradient). If COP is reduced, fluid will begin to accumulate in \line \up
0 \expndtw-2\charscalex100 the interstitium, producing edema. In the cerebral ca
pillaries, Fenstermacher [5] \line \dn2 \expndtw-2\charscalex100 calculated the
effective pore size to be only 7 to 9 \up2 \expndtw-2\charscalex100 \u730? \dn2
\expndtw-3\charscalex100 . This small pore size of the \par\pard\ql \li1049\sb30
\sl-230\slmult0 \up0 \expndtw-3\charscalex100 blood - brain barrier (BBB) preven
ts not only the movement of proteins, but also \par\pard\sect\sectd\fs24\paperw8

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\pard\sb0\sl-240{\bkmkstart Pg3}{\bkmkend Pg3}\par\pard\li2326\sb0\sl-184\slmult

0\par\pard\li2326\sb0\sl-184\slmult0\par\pard\li2326\sb0\sl-184\slmult0\par\pard
\li2326\sb0\sl-184\slmult0\par\pard\li2326\sb112\sl-184\slmult0\fi0\tx7350 \up0
\expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs16 C. Tommasino / Anesthesiol
ogy Clin N Am 20 (2002) 329-346\tab \up0 \expndtw-1\charscalex100 331\par\pard\q
j \li1133\sb0\sl-200\slmult0 \par\pard\qj\li1133\sb0\sl-200\slmult0 \par\pard\qj
\li1133\sb0\sl-200\slmult0 \par\pard\qj\li1133\sb0\sl-200\slmult0 \par\pard\qj\l
i1133\sb0\sl-200\slmult0 \par\pard\qj\li1133\sb0\sl-200\slmult0 \par\pard\qj\li1
133\sb0\sl-200\slmult0 \par\pard\qj\li1133\sb0\sl-200\slmult0 \par\pard\qj\li113
3\sb0\sl-200\slmult0 \par\pard\qj\li1133\sb0\sl-200\slmult0 \par\pard\qj\li1133\
sb0\sl-200\slmult0 \par\pard\qj\li1133\sb0\sl-200\slmult0 \par\pard\qj\li1133\sb
0\sl-200\slmult0 \par\pard\qj\li1133\sb0\sl-200\slmult0 \par\pard\qj\li1133\sb0\
sl-200\slmult0 \par\pard\qj\li1133\sb0\sl-200\slmult0 \par\pard\qj\li1133\sb0\sl
-200\slmult0 \par\pard\qj\li1133\sb0\sl-200\slmult0 \par\pard\qj\li1133\sb0\sl-2
00\slmult0 \par\pard\qj\li1133\sb0\sl-200\slmult0 \par\pard\qj\li1133\sb0\sl-200
\slmult0 \par\pard\qj\li1133\sb0\sl-200\slmult0 \par\pard\qj\li1133\sb0\sl-200\s
lmult0 \par\pard\qj\li1133\sb0\sl-200\slmult0 \par\pard\qj\li1133\sb0\sl-200\slm
ult0 \par\pard\qj\li1133\sb0\sl-200\slmult0 \par\pard\qj\li1133\ri863\sb82\sl-20
0\slmult0\fi0 \up0 \expndtw-2\charscalex100 Fig. 1. Schematic diagram of capilla
ry membrane in the periphery. (A) The vessel wall is permeable to \up0 \expndtw1\charscalex100 both water (H\ul0\sub\cf10\f11\fs17 2\ul0\nosupersub\cf9\f10\fs1
6 O) and small ions, but not to proteins (P), in the brain. (B) The blood - brai
n barrier is \up0 \expndtw-1\charscalex100 permeable only to water. \par\pard\qj
\li1133\sb0\sl-240\slmult0 \par\pard\qj\li1133\sb0\sl-240\slmult0 \par\pard\qj\
li1133\ri891\sb87\sl-240\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\c
f4\f5\fs20 sodium, chloride, and potassium ions [5] (Fig. 1B). The fluid movemen
t across \line \up0 \expndtw-2\charscalex100 the BBB is determined by the \u8216
?\u8216?total\u8217?\u8217? osmotic gradient, generated both by large \line \up0
\expndtw-2\charscalex100 molecules and small ions. Because there are so few pro
tein molecules compared \line \up0 \expndtw0\charscalex102 with the number of in
organic ions, their effect on total osmolality is minimal \line \up0 \expndtw-3\
charscalex100 (normal COP \up0 \expndtw-2\charscalex100 20 mmHg \up0 \expndtw-2\
charscalex100 1 mOsm/kg). Clearly, the influence of changes in \par\pard\qj \li1
133\ri892\sb0\sl-240\slmult0 \up0 \expndtw-3\charscalex100 osmolality on cerebra
l water distribution dwarfs the effects of alteration in COP. \up0 \expndtw0\cha
rscalex100 These differences explain why the administration of large volumes of
isotonic \up0 \expndtw0\charscalex100 crystalloids, with dilutional reduction of
COP, results in peripheral edema, but \up0 \expndtw-3\charscalex100 does not in
crease brain water content and/or ICP [6 - 8]. \par\pard\qj \li1133\ri892\sb0\sl
-240\slmult0\fi239 \up0 \expndtw-3\charscalex100 When plasma osmolality decrease
s, the osmotic gradient drives water into the \up0 \expndtw0\charscalex100 brain
tissue. Even small changes in plasma osmolality ( < 5%) increase brain \up0 \ex
pndtw-2\charscalex100 water content and ICP [7]. \par\pard\qj \li1133\ri831\sb4\
sl-236\slmult0\fi239 \up0 \expndtw-2\charscalex100 The above scenario describes
the situation in conditions of normal BBB. After \line \up0 \expndtw0\charscalex
103 a brain lesion, according to the severity of the damage (head trauma, tumor,
\line \up0 \expndtw-3\charscalex100 seizure, abscess, or other damage), there c
an be varying degrees of BBB integrity, \line \up0 \expndtw0\charscalex100 which
can respond differently to the osmotic/oncotic changes. With complete \line \up
0 \expndtw0\charscalex102 breakdown of the BBB, no osmotic gradient can be estab
lished [9 - 11]. It is \line \up0 \expndtw0\charscalex104 possible that with a l
ess severe injury to the BBB, the barrier may function \line \up0 \expndtw0\char
scalex102 similarly to the peripheral tissue \up0 \expndtw0\charscalex103 [12].
Finally, there is usually a significant \par\pard\sect\sectd\fs24\paperw8640\pap
erh12960\pard\sb0\sl-240{\bkmkstart Pg4}{\bkmkend Pg4}\par\pard\li1049\sb0\sl-18
4\slmult0\par\pard\li1049\sb0\sl-184\slmult0\par\pard\li1049\sb0\sl-184\slmult0\
par\pard\li1049\sb0\sl-184\slmult0\par\pard\li1049\sb112\sl-184\slmult0\fi0\tx22
43 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs16 332\tab \up0 \expn
dtw-1\charscalex100 C. Tommasino / Anesthesiology Clin N Am 20 (2002) 329-346\pa
r\pard\qj \li1049\sb0\sl-240\slmult0 \par\pard\qj\li1049\ri977\sb9\sl-240\slmult
0 \up0 \expndtw0\charscalex103 \ul0\nosupersub\cf4\f5\fs20 portion of the brain

where the BBB is normal. The presence of a functionally \up0 \expndtw0\charscale

x100 intact BBB is essential if osmotherapy is to be successful [13]. \par\pard\
ql \li1049\sb0\sl-230\slmult0 \par\pard\ql\li1049\sb0\sl-230\slmult0 \par\pard\q
l\li1049\sb29\sl-230\slmult0 \up0 \expndtw0\charscalex105 Hematocrit and hemodil
ution \par\pard\qj \li1049\ri915\sb142\sl-240\slmult0\fi239 \up0 \expndtw0\chars
calex100 One common accompaniment of fluid infusion is a reduction in hemoglobin
/ \line \up0 \expndtw-3\charscalex100 hematocrit. This hemodilution is typically
accompanied by an increase in cerebral \line \up0 \expndtw0\charscalex100 blood
flow (CBF) [7,14,15]. In the normal brain, the increase in CBF produced \line \
up0 \expndtw0\charscalex104 by hemodilution is an active compensatory response t
o a decrease in arterial \line \up0 \expndtw0\charscalex108 oxygen content, and
this response is essentially identical to that seen with \line \up0 \expndtw-1\c
harscalex100 hypoxia [16 - 18]. However, it should be stressed that in the face
of brain injury, \line \up0 \expndtw0\charscalex102 the normal CBF responses to
hypoxia and to hemodilution are attenuated, and \line \up0 \expndtw-1\charscalex
100 both changes may contribute to secondary tissue damage [19]. \par\pard\qj \l
i1049\ri933\sb0\sl-240\slmult0\fi239 \up0 \expndtw-2\charscalex100 A hematocrit
level of 30 - 33% gives the optimal combination of viscosity and \line \up0 \exp
ndtw-1\charscalex100 O\ul0\sub\cf8\f9\fs21 2\ul0\nosupersub\cf4\f5\fs20 carryin
g capacity, and may improve neurologic outcome [6,20,21]. However, \line \up0 \e
xpndtw-2\charscalex100 marked hemodilution (Hct < 30%) exacerbates neurologic in
jury [20,22]. \par\pard\ql \li1049\sb0\sl-230\slmult0 \par\pard\ql\li1049\sb0\sl
-230\slmult0 \par\pard\ql\li1049\sb29\sl-230\slmult0 \up0 \expndtw0\charscalex10
6 Fluids for intravenous administration \par\pard\qj \li1049\ri923\sb142\sl-240\
slmult0\fi239 \up0 \expndtw-2\charscalex100 The anesthesiologists and the intens
ivists can choose among a variety of fluids \line \up0 \expndtw0\charscalex102 s
uitable for intravenous administration, commonly categorized as crystalloids \li
ne \up0 \expndtw-2\charscalex100 and colloids. \par\pard\ql \li1049\sb0\sl-230\s
lmult0 \par\pard\ql\li1049\sb19\sl-230\slmult0 \up0 \expndtw-1\charscalex100 Cry
stalloids and cerebral effects of plasma osmolality \par\pard\qj \li1049\ri976\s
b142\sl-240\slmult0\fi239 \up0 \expndtw0\charscalex102 Crystalloid solutions do
not contain any high molecular weight compound, \up0 \expndtw0\charscalex103 and
have an oncotic pressure of zero. Crystalloids may be hypo-osmolar, iso\up0 \ex
pndtw-1\charscalex100 osmolar or hyperosmolar, and may or may not contain glucos
e. Commonly used \up0 \expndtw-2\charscalex100 crystalloid solutions are illustr
ated in Table 1. \par\pard\ql \li1049\sb0\sl-230\slmult0 \par\pard\ql\li1049\sb3
9\sl-230\slmult0 \up0 \expndtw-2\charscalex100 Hypo-osmolar crystalloids \par\pa
rd\qj \li1049\ri915\sb5\sl-237\slmult0\fi239 \up0 \expndtw0\charscalex106 Since
the early years of the last century, scientists have known that fluid \line \up0
\expndtw-3\charscalex100 regimens provide free water (eg, 0.45% saline or 5% gl
ucose in water, D5W), and \line \up0 \expndtw0\charscalex100 cause a concomitant
reduction in plasma osmolality, can cause cerebral edema. \line \up0 \expndtw0\
charscalex104 One of the first animal studies on the cerebral effects of fluid a
dministration \line \up0 \expndtw0\charscalex100 showed that hypotonic solutions
expanded the brain [23]. The osmotic gradient \line \up0 \expndtw0\charscalex10
6 drives water across the BBB into the cerebral tissue, increasing brain water \
line \up0 \expndtw-3\charscalex100 content (= edema) and ICP. As a consequence,
the use of fluid therapy that avoids \line \up0 \expndtw0\charscalex102 excess f
ree water has been a standard element of management in patients with \line \up0
\expndtw-1\charscalex100 brain and spinal cord damage. \par\pard\ql \li1049\sb0\
sl-230\slmult0 \par\pard\ql\li1049\sb39\sl-230\slmult0 \up0 \expndtw-2\charscale
x100 Iso-osmolar crystalloids \par\pard\qj \li1049\ri977\sb2\sl-240\slmult0\fi23
9 \up0 \expndtw0\charscalex103 Although some clinicians have long believed that
iso-osmolar crystalloids \line \up0 \expndtw0\charscalex100 induce and/or aggrav
ate brain edema, the many attempts to demonstrate experi-\par\pard\sect\sectd\fs
24\paperw8640\paperh12960{\shp
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Na\ul0\super\cf10\f11\fs16 +\ul0\nosupersub\cf9\f10\fs16
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alex100 525\tab \up0 \expndtw-1\charscalex100 130\tab \up0 \expndtw-1\charscalex
100 109\tab \up0 \expndtw-1\charscalex100 4\tab \up0 \expndtw-1\charscalex100 3\
tab \up0 \expndtw-1\charscalex100 50\par\pard\li1133\sb15\sl-184\slmult0\fi0\tx3
538\tx4280\tx4764\tx5168\tx5448 \up0 \expndtw-1\charscalex100 Ringer\u8217?s sol
ution\tab \up0 \expndtw-1\charscalex100 309\tab \up0 \expndtw-1\charscalex100 14
7\tab \up0 \expndtw-1\charscalex100 156\tab \up0 \expndtw-1\charscalex100 4\tab
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harscalex100 130\tab \up0 \expndtw-1\charscalex100 109\tab \up0 \expndtw-1\chars
calex100 4\tab \up0 \expndtw-1\charscalex100 3\tab \up0 \expndtw-1\charscalex100
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ndtw-1\charscalex100 525\tab \up0 \expndtw-1\charscalex100 130\tab \up0 \expndtw
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\up0 \expndtw-1\charscalex100 77\par\pard\li1133\sb14\sl-184\slmult0\fi0\tx3538\

tx4280\tx4764 \up0 \expndtw-1\charscalex100 0.9% NaCl\tab \up0 \expndtw-1\charsc
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tw-1\charscalex100 3.0% Saline\tab \up0 \expndtw-1\charscalex100 1026\tab \up0 \
expndtw-1\charscalex100 513\tab \up0 \expndtw-1\charscalex100 513\par\pard\li113
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% Saline\tab \up0 \expndtw-1\charscalex100 1710\tab \up0 \expndtw-1\charscalex10
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fi0\tx3458\tx4200\tx4685 \up0 \expndtw-1\charscalex100 7.5% Saline\tab \up0 \exp
ndtw-1\charscalex100 2566\tab \up0 \expndtw-1\charscalex100 1283\tab \up0 \expnd
tw-1\charscalex100 1283\par\pard\li1133\sb14\sl-184\slmult0\fi0\tx3458 \up0 \exp
ndtw-1\charscalex100 20% Mannitol\tab \up0 \expndtw-1\charscalex100 1098\par\par
d\li1133\sb85\sl-184\slmult0\fi239\tx5725\tx6113 \up0 \expndtw-1\charscalex100 \
ul0\super\cf10\f11\fs16 a\ul0\nosupersub\cf9\f10\fs16 osmolarity = calculated v
alue (osm/l = mg molecular weigh\tab \up0 \expndtw-1\charscalex100 10\tab \up0
\expndtw-1\charscalex100 valence).\par\pard\ql \li1373\sb9\sl-184\slmult0 \up0
\expndtw-1\charscalex100 \ul0\super\cf10\f11\fs16 b\ul0\nosupersub\cf9\f10\fs16
Acetate 27 mEq/l and gluconate 23 mEq/l. \par\pard\qj \li1133\sb0\sl-240\slmult
0 \par\pard\qj\li1133\sb0\sl-240\slmult0 \par\pard\qj\li1133\ri883\sb30\sl-240\s
lmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf4\f5\fs20 mentally this ph
enomenon have not yielded scientifically convincing proof or \line \up0 \expndtw
-1\charscalex100 have generated negative results [7 - 11,24 - 27]. Iso-osmolar s
olutions, with an \line \up0 \expndtw-3\charscalex100 osmolality \up0 \expndtw0\
charscalex104 300 mOsm/L, such as plasmalyte, 0.9% saline, do not change \line \
up0 \expndtw-1\charscalex100 plasma osmolality, and do not increase brain water
content. The same does not \line \up0 \expndtw0\charscalex104 apply to solutions
that are not truly iso-osmolar with respect to plasma. For \line \up0 \expndtw1\charscalex100 example, commercial lactated Ringer\u8217?s solution has a calcu
lated osmolarity of \par\pard\ql \li1322\sb9\sl-230\slmult0\tx5448 \up0 \expndtw
0\charscalex104 275 mOsm/L, but a measured osmolality of \tab \up0 \expndtw0\cha
rscalex100 254 mOsm/kg, indicating \par\pard\qj \li1133\ri892\sb2\sl-240\slmult0
\up0 \expndtw-3\charscalex100 incomplete dissociation [7]. The administration o
f large volumes of this solution \up0 \expndtw-3\charscalex100 (> 3 l in humans)
can reduce plasma osmolality and increase brain water content \up0 \expndtw-2\c
harscalex100 and ICP [7,28], as approximately 114 mL of free water is given for
each liter of \up0 \expndtw-4\charscalex100 lactated Ringer\u8217?s solution. \p
ar\pard\ql \li1133\sb0\sl-230\slmult0 \par\pard\ql\li1133\sb79\sl-230\slmult0 \u
p0 \expndtw-4\charscalex100 Hyperosmolar crystalloids \par\pard\qj \li1133\ri890
\sb2\sl-240\slmult0\fi239 \up0 \expndtw-1\charscalex100 Crystalloids may be made
hyperosmolar by the inclusion of electrolytes (eg, \line \up0 \expndtw-1\charsc
alex100 Na\ul0\super\cf8\f9\fs21 +\ul0\nosupersub\cf4\f5\fs20 and Cl , as in h
ypertonic saline), or low molecular weight solutes, such as \line \up0 \expndtw0
\charscalex100 mannitol (molecular weight 182), or glucose (molecular weight 180
). Hyper-\line \up0 \expndtw0\charscalex102 osmolar solutions exert their benefi
cial effects by osmotically shifting water \line \up0 \expndtw-1\charscalex100 f
rom the nervous tissue (intracellular and interstitial space) to the intravascul
ar \line \up0 \expndtw0\charscalex103 space. This effect has been demonstrated i
n brain tissue with normal a BBB \line \up0 \expndtw-1\charscalex100 [13,28 - 31
], and is the cornerstone treatment of intracranial hypertension. Fur-\line \up0
\expndtw0\charscalex102 thermore, the increased serum osmolality reduces cerebr
ospinal fluid \up0 \expndtw-3\charscalex100 (CSF) \par\pard\qj \li1133\ri880\sb0
\sl-240\slmult0 \up0 \expndtw0\charscalex102 secretion rate, and this effect can
contribute to improve the intracranial com\up0 \expndtw-3\charscalex100 pliance
[32 - 34]. \par\pard\sect\sectd\fs24\paperw8640\paperh12960{\shp
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}
\pard\sb0\sl-240{\bkmkstart Pg6}{\bkmkend Pg6}\par\pard\li1049\sb0\sl-184\slmult
0\par\pard\li1049\sb0\sl-184\slmult0\par\pard\li1049\sb0\sl-184\slmult0\par\pard
\li1049\sb0\sl-184\slmult0\par\pard\li1049\sb112\sl-184\slmult0\fi0\tx2243 \up0
\expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs16 334\tab \up0 \expndtw-1\ch
arscalex100 C. Tommasino / Anesthesiology Clin N Am 20 (2002) 329-346\par\pard\l
i1049\sb0\sl-184\slmult0\par\pard\li1049\sb74\sl-184\slmult0\fi0 \up0 \expndtw-1
\charscalex100 Table 2\par\pard\li1049\sb16\sl-184\slmult0\fi0 \up0 \expndtw-1\c
harscalex100 Composition of commonly used intravenous fluids: Colloids\par\pard\
li1049\sb85\sl-184\slmult0\fi2379\tx5381\tx6431 \up2 \expndtw-1\charscalex100 mE
q/l\tab \dn3 \expndtw-1\charscalex100 Osmolarity\ul0\super\cf10\f11\fs16 a\tab \
dn3 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs16 Oncotic pressure\par\p
ard\li1049\sb94\sl-184\slmult0\fi0\tx3429\tx4507\tx5381\tx6431 \up0 \expndtw-1\c
harscalex100 Intravenous fluids\tab \up0 \expndtw-1\charscalex100 Na\ul0\super\c
f10\f11\fs16 +\ul0\nosupersub\cf9\f10\fs16
Cl\tab \up0 \expndtw-1\charscal
ex100 K
Ca\tab \up0 \expndtw-1\charscalex100 (mOsm/l)\tab \up0 \expndtw-1\cha
rscalex100 (mm Hg)\par\pard\li1049\sb95\sl-184\slmult0\fi0\tx3429\tx4052\tx4507\
tx4943\tx5610\tx6431 \up0 \expndtw-1\charscalex100 Fresh-frozen plasma\tab \up0
\expndtw-1\charscalex100 168\tab \up0 \expndtw-1\charscalex100 76\tab \up0 \expn
dtw-1\charscalex100 3.2\tab \up0 \expndtw-1\charscalex100 8.2\tab \up0 \expndtw1\charscalex100 300\tab \up0 \expndtw-1\charscalex100 21\par\pard\li1049\sb16\sl
-184\slmult0\fi0\tx5619\tx6431 \up0 \expndtw-1\charscalex100 5% Albumin\tab \up0

\expndtw-1\charscalex100 290\tab \up0 \expndtw-1\charscalex100 19\par\pard\li10

49\sb16\sl-184\slmult0\fi0\tx3429\tx3972\tx5610\tx6431 \up0 \expndtw-1\charscale
x100 Dextran (10%) 40 in 0.9% saline\tab \up0 \expndtw-1\charscalex100 154\tab \
up0 \expndtw-1\charscalex100 154\tab \up0 \expndtw-1\charscalex100 310\tab \up0
\expndtw-1\charscalex100 61\par\pard\li1049\sb15\sl-184\slmult0\fi0\tx3429\tx397
2\tx5610\tx6431 \up0 \expndtw-1\charscalex100 Dextran (6%) 70 in 0.9% saline\tab
\up0 \expndtw-1\charscalex100 154\tab \up0 \expndtw-1\charscalex100 154\tab \up
0 \expndtw-1\charscalex100 310\tab \up0 \expndtw-1\charscalex100 19\par\pard\li1
049\sb15\sl-184\slmult0\fi0\tx3429\tx3972\tx6431 \up0 \expndtw-1\charscalex100 H
etastarch (6%) in 0.9% saline\tab \up0 \expndtw-1\charscalex100 154\tab \up0 \ex
pndtw-1\charscalex100 154\tab \up0 \expndtw-1\charscalex100 31\par\pard\li1049\s
b15\sl-184\slmult0\fi0\tx3429\tx3972\tx5610\tx6431 \up0 \expndtw-1\charscalex100
Hetastarch (10%) in 0.9% saline\tab \up0 \expndtw-1\charscalex100 154\tab \up0
\expndtw-1\charscalex100 154\tab \up0 \expndtw-1\charscalex100 310\tab \up0 \exp
ndtw-1\charscalex100 82\par\pard\li1049\sb85\sl-184\slmult0\fi239\tx5677\tx6065
\up0 \expndtw-1\charscalex100 \ul0\super\cf10\f11\fs16 a\ul0\nosupersub\cf9\f10\
fs16 Osmolarity = calculated value (osm/l = mg molecular weigh\tab \up0 \expn
dtw-1\charscalex100 10\tab \up0 \expndtw-1\charscalex100 valence).\par\pard\ql \
li1049\sb0\sl-230\slmult0 \par\pard\ql\li1049\sb13\sl-230\slmult0 \up0 \expndtw1\charscalex100 \ul0\nosupersub\cf4\f5\fs20 Colloids and cerebral effects of col
loid oncotic pressure \par\pard\qj \li1049\ri915\sb142\sl-240\slmult0\fi239 \up0
\expndtw0\charscalex105 Colloid is the term used to denote solutions that have
an oncotic pressure \line \up0 \expndtw0\charscalex111 similar to that of plasma
. Colloidal solutions share the presence of large \line \up0 \expndtw-2\charscal
ex100 molecules that are relatively impermeable to the capillary membranes. Freq
uently \line \up0 \expndtw0\charscalex107 used colloids are illustrated in Table
\up0 \expndtw0\charscalex105 2. Colloids include albumin, plasma, \par\pard\ql
\li1049\sb9\sl-230\slmult0\tx1982\tx5366\tx6937 \up0 \expndtw-1\charscalex100 he
tastarch \tab \up0 \expndtw0\charscalex103 (hydroxyethylstarch, molecular weight
\tab \up0 \expndtw0\charscalex103 450), pentastarch \tab \up0 \expndtw0\charsca
lex110 (a low \par\pard\ql \li1049\sb10\sl-230\slmult0 \up0 \expndtw-2\charscale
x100 molecular weight, 264, hydroxyethylstarch), and the dextrans (molecular wei
ghts \par\pard\qj \li1049\ri976\sb2\sl-240\slmult0 \up0 \expndtw0\charscalex110
40 and 70). Dextran and hetastarch are dissolved in normal saline, so the \up0 \
expndtw0\charscalex100 osmolarity of the solution is approximately 290 to 310 mO
sm/L, with a sodium \up0 \expndtw-1\charscalex100 and chloride content of about
154 mEq/L each. \par\pard\qj \li1049\ri976\sb2\sl-238\slmult0\fi239 \up0 \expndt
w0\charscalex109 Although it is accepted that a reduction in serum osmolality wi
ll cause \line \up0 \expndtw0\charscalex104 cerebral edema [7,12,23], there is n
ot uniform agreement about the potential \line \up0 \expndtw0\charscalex104 effe
ct of reduction in COP. Carefully conducted investigations have system-\line \up
0 \expndtw0\charscalex106 atically sought a cerebral edema effect of COP reducti
on but have failed to \line \up0 \expndtw0\charscalex105 identify one [6,8 - 11]
. Only a recent and elegant study by Drummond et al. \line \up0 \expndtw0\charsc
alex100 [12] has reported that COP reduction has the potential to aggr
avate brain \line \up0 \expndtw0\charscalex100 edema. The different results can
be explained by the nature and severity of the \line \up0 \expndtw0\charscalex1
02 brain injury. In the study of Drummond et al. [12], the injury was deliberate
ly \line \up0 \expndtw0\charscalex100 mild. It seem reasonable to suspect that t
his type of mechanical injury made the \line \up0 \expndtw0\charscalex100 BBB pe
rmeable to low molecular weight solutes while remaining impermeable \line \up0 \
expndtw-1\charscalex100 to colloids. \par\pard\qj \li1049\ri975\sb1\sl-240\slmul
t0\fi239 \up0 \expndtw0\charscalex102 From the above-mentioned studies we can po
stulate that, depending on the \line \up0 \expndtw0\charscalex108 severity of th
e BBB damage, we will have brain areas where the osmotic/ \line \up0 \expndtw0\c
harscalex100 oncotic gradient is totally effective (normal BBB), areas where onl
y the colloid \line \up0 \expndtw-1\charscalex100 oncotic gradient is effective
(mild opening of the BBB, with pore size similar to \line \up0 \expndtw0\charsca
lex107 the periphery), and areas where there is no osmotic/oncotic gradient effe
ct \line \up0 \expndtw-1\charscalex100 (BBB breakdown). \par\pard\qj \li1049\ri9

41\sb0\sl-240\slmult0\fi239 \up0 \expndtw0\charscalex100 The message is to avoid

and/or correct, in patients with brain or spinal cord \line \up0 \expndtw-2\cha
rscalex100 injury, a decrease in \u8216?\u8216?both\u8217?\u8217? serum osmolali
ty and COP. This message, however, \line \up0 \expndtw-2\charscalex100 is part o
f the \u8216?\u8216?common clinical sense.\u8217?\u8217? As anesthesiologists an
d intensivists, we \line \up0 \expndtw0\charscalex105 treat not only brains but
patients, and a COP reduction, even if it could not \line \up0 \expndtw0\charsca
lex106 directly affect brain water content, affects other organs and perfusion \
up0 \expndtw-4\charscalex100 (eg, \par\pard\ql \li1049\sb9\sl-230\slmult0 \up0 \
expndtw-2\charscalex100 pulmonary edema) [35], which in turn, can influence brai
n homeostasis. \par\pard\sect\sectd\fs24\paperw8640\paperh12960\pard\sb0\sl-240{
\bkmkstart Pg7}{\bkmkend Pg7}\par\pard\li2326\sb0\sl-184\slmult0\par\pard\li2326
\sb0\sl-184\slmult0\par\pard\li2326\sb0\sl-184\slmult0\par\pard\li2326\sb0\sl-18
4\slmult0\par\pard\li2326\sb112\sl-184\slmult0\fi0\tx7350 \up0 \expndtw-1\charsc
alex100 \ul0\nosupersub\cf9\f10\fs16 C. Tommasino / Anesthesiology Clin N Am 20
(2002) 329-346\tab \up0 \expndtw-1\charscalex100 335\par\pard\ql \li1133\sb197\s
l-230\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf4\f5\fs20 Glucosecontaining solutions \par\pard\qj \li1133\ri830\sb144\sl-238\slmult0\fi239 \up0
\expndtw0\charscalex106 Intravenous salt-free solutions containing glucose shoul
d be avoided in \line \up0 \expndtw-3\charscalex100 patients with brain and spin
al cord pathology. Once glucose is metabolized, only \line \up0 \expndtw-3\chars
calex100 free water remains only free water, which reduces serum osmolality and
increases \line \up0 \expndtw-2\charscalex100 brain water content. Furthermore,
several studies in animals as well as in humans \line \up0 \expndtw-2\charscalex
100 have demonstrated that glucose administration increases neurologic damage an
d \line \up0 \expndtw-2\charscalex100 can worsen outcome from both focal and glo
bal ischemia [36 - 40], presumably \line \up0 \expndtw-2\charscalex100 because i
n ischemic areas glucose metabolism enhances tissue acidosis [40,41]. \line \up0
\expndtw-3\charscalex100 Glucose-containing solutions should be withheld in adu
lt neurosurgical patients, \line \up0 \expndtw-3\charscalex100 with the exceptio
n of neonates and patients with diabetes, in whom hypoglycemia \line \up0 \expnd
tw-2\charscalex100 can occur very rapidly and be detrimental. It should be noted
that this caveat does \line \up0 \expndtw0\charscalex105 not appear to apply to
the use of hyperalimentation fluids in neurosurgical \line \up0 \expndtw-3\char
scalex100 patients, perhaps because these hyperglycemic fluids are typically sta
rted several \line \up0 \expndtw0\charscalex103 days after the primary insult, a
nd/or because concomitant insulin is used. In \line \up0 \expndtw0\charscalex100
humans, it has not been carefully studied whether aggressive control of hyper-\
line \up0 \expndtw0\charscalex100 glycemia with insulin will improve outcome, bu
t laboratory evidence supports \line \up0 \expndtw0\charscalex105 the concept th
at preischemic correction of hyperglycemia with insulin im-\line \up0 \expndtw-3
\charscalex100 proves outcome. \par\pard\qj \li1133\ri891\sb1\sl-240\slmult0\fi2
39 \up0 \expndtw0\charscalex100 In neurosurgical patients blood sugar level shou
ld be controlled frequently, \up0 \expndtw0\charscalex100 and the goal should be
to avoid either hypo-and hyperglycemia, and maintain \up0 \expndtw-2\charscalex
100 sugar levels between 100 and 150 mg/dL. \par\pard\qj \li1133\ri3857\sb302\sl
-480\slmult0 \up0 \expndtw0\charscalex104 Fluids to control ICP and brain swelli
ng \up0 \expndtw-3\charscalex100 Diuretics: mannitol and furosemide \par\pard\qj
\li1133\ri832\sb79\sl-240\slmult0\fi239 \up0 \expndtw-1\charscalex100 Both mann
itol and furosemide are extensively used to control ICP and brain \line \up0 \ex
pndtw0\charscalex100 swelling. Mannitol accomplishes this goal by establishing a
n osmotic gradient \line \up0 \expndtw0\charscalex103 between the intravascular
compartment and the cerebral parenchyma, in the \line \up0 \expndtw-1\charscalex
100 presence of a relatively intact BBB. The increased plasma osmolality promote
s \line \up0 \expndtw0\charscalex100 removal of water from areas of normal brain
[29,33]. Several issues related to \line \up0 \expndtw-2\charscalex100 mannitol
have also been clarified in recent years. Mannitol can transiently elevate \lin
e \up0 \expndtw0\charscalex102 ICP. The mechanism of this effect is clearly due
to the vasodilator effects of \line \up0 \expndtw0\charscalex103 hyperosmolality
, with a resultant increase in cerebral blood volume \up0 \expndtw-3\charscalex1

00 (CBV) \par\pard\qj \li1133\ri892\sb0\sl-240\slmult0 \up0 \expndtw0\charscalex

104 [42,43]. However, it has been shown in both dogs and humans that this is a \
up0 \expndtw-2\charscalex100 phenomenon that does not occur in the presence of i
ntracranial hypertension, or \up0 \expndtw0\charscalex100 when mannitol is given
at moderate rates [42,43]. Thus, there is no important \up0 \expndtw0\charscale
x100 reason to avoid mannitol in most neurosurgical patients, other than in pati
ents \up0 \expndtw-3\charscalex100 with significant cardiovascular disease, in w
hom the transient volume expansion \up0 \expndtw-4\charscalex100 might precipita
te congestive heart failure. \par\pard\qj \li1133\ri846\sb0\sl-240\slmult0\fi239
\up0 \expndtw-2\charscalex100 The other important concern is the excessive and/
or repeated use of the drug, \line \up0 \expndtw-2\charscalex100 because excessi
ve hyperosmolality can be detrimental. In addition, mannitol does \line \up0 \ex
pndtw-2\charscalex100 progressively accumulate in the interstitium with repeated
doses, and may even \line \up0 \expndtw-2\charscalex100 aggravate brain edema [
44,45]. If interstitial osmolality rises excessively, it is \par\pard\sect\sectd
\fs24\paperw8640\paperh12960\pard\sb0\sl-240{\bkmkstart Pg8}{\bkmkend Pg8}\par\p
ard\li1049\sb0\sl-184\slmult0\par\pard\li1049\sb0\sl-184\slmult0\par\pard\li1049
\sb0\sl-184\slmult0\par\pard\li1049\sb0\sl-184\slmult0\par\pard\li1049\sb112\sl184\slmult0\fi0\tx2243 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs1
6 336\tab \up0 \expndtw-1\charscalex100 C. Tommasino / Anesthesiology Clin N Am
20 (2002) 329-346\par\pard\qj \li1049\sb0\sl-240\slmult0 \par\pard\qj\li1049\ri9
76\sb9\sl-240\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf4\f5\fs20 p
ossible that the normal brain - blood gradient might be reversed, with resultant
\up0 \expndtw0\charscalex100 worsened edema. Furthermore, if brain osmolality i
s increased, there is a risk of \up0 \expndtw-1\charscalex100 enhancing edema by
subsequent normalization of serum osmolality. \par\pard\qj \li1049\ri976\sb4\sl
-236\slmult0\fi239 \up0 \expndtw0\charscalex100 Although mannitol is extensively
used in patients with intracranial hyperten-\line \up0 \expndtw0\charscalex100
sion, a larger dose-finding study in humans has not been performed, and single \
line \up0 \expndtw-1\charscalex100 doses of mannitol from 0.25 up to 2.27 g/kg h
ave been reported in the literature. \line \up0 \expndtw-1\charscalex100 Marchal
l et al. [46] studied the effect of different mannitol doses in patients, and \l
ine \up0 \expndtw0\charscalex100 concluded that small doses (0.25 g/kg) were as
effective as larger doses. At our \line \up0 \expndtw0\charscalex104 institution
mannitol is used at a dose range of 0.25 - 1.0 g/kg, and we always \line \up0 \
expndtw0\charscalex100 choose the smallest possible dose, which is infused in at
least in 10 - 15 min. \par\pard\qj \li1049\ri914\sb1\sl-240\slmult0\fi239 \up0
\expndtw0\charscalex102 The mechanism of furosemide\u8217?s action remains contr
oversial (although it \line \up0 \expndtw-1\charscalex100 certainly is related t
o the drug\u8217?s ability to block Cl transport) [47]. Furosemide \line \up0 \
expndtw-2\charscalex100 and similar drugs may also act primarily by reducing cel
l swelling, rather than by \line \up0 \expndtw-2\charscalex100 changing extracel
lular fluid volume. In several studies it has been demonstrated \line \up0 \expn
dtw0\charscalex106 that furosemide decreases CSF production, and this effect can
explain the \line \up0 \expndtw0\charscalex100 synergism between mannitol and f
urosemide on intracranial compliance [48]. \line \up0 \expndtw-3\charscalex100 F
urosemide\u8217?s maximal effect is delayed compared with mannitol [49,50]. For
this \line \up0 \expndtw-3\charscalex100 reason, mannitol probably remains the a
gent of choice for rapid ICP control. \par\pard\ql \li1049\sb0\sl-230\slmult0 \p
ar\pard\ql\li1049\sb119\sl-230\slmult0 \up0 \expndtw-3\charscalex100 Hypertonic
saline solutions \par\pard\qj \li1049\ri916\sb145\sl-237\slmult0\fi239 \up0 \exp
ndtw0\charscalex100 Hypertonic salt solutions have been primarily used for small
-volume resus-\line \up0 \expndtw-2\charscalex100 citation in patients with hemo
rrhagic shock. Because hyperosmolality is known \line \up0 \expndtw0\charscalex1
03 to reduce brain volume [23], hypertonic saline may become part of standard \l
ine \up0 \expndtw0\charscalex100 resuscitation in patients with concomitant head
injury. Laboratory and clinical \line \up0 \expndtw-3\charscalex100 data sugges
t that hypertonic solutions are effective for volume resuscitation, and \line \u
p0 \expndtw-2\charscalex100 result in a lesser degree of cerebral edema [51,52].
In humans, acute resuscitation \line \up0 \expndtw-2\charscalex100 from hemorrh

agic shock with 7.5% hypertonic saline is associated with improved \line \up0 \e
xpndtw0\charscalex100 outcome in traumatized head-injured patients, and clinical
studies suggest that \line \up0 \expndtw-2\charscalex100 hypertonic saline may
be efficacious in hypotensive, brain-injured patients during \line \up0 \expndtw
-3\charscalex100 transport to the hospital [53,54]. \par\pard\qj \li1049\ri916\s
b1\sl-240\slmult0\fi239 \up0 \expndtw0\charscalex100 Various animal experiments
have indicated that hypertonic saline solutions \line \up0 \expndtw-3\charscalex
100 lower ICP and improve cerebral perfusion pressure [3,30,31,51]. The CNS effe
cts \line \up0 \expndtw0\charscalex104 of hypertonic saline are similar to manni
tol \up0 \expndtw0\charscalex103 [30,55]; however, the fact that \par\pard\qj \l
i1049\ri976\sb0\sl-240\slmult0 \up0 \expndtw-1\charscalex100 hypertonic saline d
oes not produce an osmotic diuresis simplifies perioperative \line \up0 \expndtw
-3\charscalex100 fluid management. There are a number of case reports and a few
controlled trials \line \up0 \expndtw0\charscalex107 that suggest that hypertoni
c saline may produce significant and sustained \line \up0 \expndtw-1\charscalex1
00 reductions in ICP where mannitol has failed [56,57]. The mechanism by which \
line \up0 \expndtw-2\charscalex100 hypertonic saline succeeded when mannitol fai
led, however, remains unclear. \par\pard\qj \li1049\ri976\sb0\sl-240\slmult0\fi2
39 \up0 \expndtw0\charscalex104 The principal disadvantage of hypertonic saline
is related to the possible \line \up0 \expndtw0\charscalex104 danger of hypernat
remia. In a recent study in neurosurgical patients during \line \up0 \expndtw0\c
harscalex100 elective procedures, we have shown that equal volumes of 20% mannit
ol and \par\pard\qj \li1049\ri976\sb0\sl-240\slmult0 \up0 \expndtw-2\charscalex1
00 7.5% hypertonic saline reduce brain bulk and cerebrospinal fluid pressure to
the \line \up0 \expndtw0\charscalex100 same extent [55]. Serum sodium levels inc
reased during the administration of \line \up0 \expndtw-2\charscalex100 hyperton
ic saline, and peaked at over 150 mEq/L at the end of the infusion [55]. \par\pa
rd\sect\sectd\fs24\paperw8640\paperh12960\pard\sb0\sl-240{\bkmkstart Pg9}{\bkmke
nd Pg9}\par\pard\li2326\sb0\sl-184\slmult0\par\pard\li2326\sb0\sl-184\slmult0\pa
r\pard\li2326\sb0\sl-184\slmult0\par\pard\li2326\sb0\sl-184\slmult0\par\pard\li2
326\sb112\sl-184\slmult0\fi0\tx7350 \up0 \expndtw-1\charscalex100 \ul0\nosupersu
b\cf9\f10\fs16 C. Tommasino / Anesthesiology Clin N Am 20 (2002) 329-346\tab \up
0 \expndtw-1\charscalex100 337\par\pard\qj \li1133\sb0\sl-237\slmult0 \par\pard\
qj\li1133\ri863\sb15\sl-237\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersu
b\cf4\f5\fs20 However, initial concerns regarding the adverse nurologic sequelae
of hypertonic \up0 \expndtw0\charscalex102 saline appear to have been premature
. First, the increment in serum sodium in \up0 \expndtw-2\charscalex100 response
to addition of concentrated sodium is less than would be predicted [55]. \up0 \
expndtw0\charscalex100 Second, patients tolerate acute increases in serum sodium
to 155 - 160 mEq/L, \up0 \expndtw0\charscalex103 without apparent harm [53 - 55
,58]. Third, central pontine myelolysis has not \up0 \expndtw0\charscalex100 bee
n observed in a clinical trial of hypertonic resuscitation [53]. One concern is
\up0 \expndtw0\charscalex100 that hypertonic saline solutions have the potential
to cause rebound intracranial \up0 \expndtw0\charscalex100 hypertension, simila
r to other osmotic agents [59,60]. \par\pard\ql \li1133\sb0\sl-230\slmult0 \par\
pard\ql\li1133\sb119\sl-230\slmult0 \up0 \expndtw-3\charscalex100 Hypertonic/hyp
eroncotic solutions \par\pard\qj \li1133\ri892\sb142\sl-240\slmult0\fi239 \up0 \
expndtw0\charscalex100 More recent attention has been directed at hypertonic/hyp
eroncotic solutions \line \up0 \expndtw0\charscalex100 (typically hypertonic het
astarch or dextran solutions). Because of the powerful \line \up0 \expndtw0\char
scalex100 hemodynamic properties of these fluids in circulatory shock, administr
ation in \line \up0 \expndtw0\charscalex100 patients with multiple traumas and h
ead injury might be particularly advantage-\line \up0 \expndtw-1\charscalex100 o
us for the prevention of secondary ischemic brain damage [58]. Small volumes \li
ne \up0 \expndtw0\charscalex105 of such solutions can restore normovolemia rapid
ly, without increasing ICP \line \up0 \expndtw0\charscalex102 [28,61]. They have
been successfully used to treat intracranial hypertension in \line \up0 \expndt
w-1\charscalex100 head-injured patients and in patients with stroke [53,54,62,63
]. \par\pard\ql \li1133\sb0\sl-230\slmult0 \par\pard\ql\li1133\sb0\sl-230\slmult
0 \par\pard\ql\li1133\sb129\sl-230\slmult0 \up0 \expndtw0\charscalex106 Implicat

ions for patient care \par\pard\ql \li1373\sb150\sl-230\slmult0\tx6859 \up0 \exp

ndtw0\charscalex112 The available information can be used to make a series of \t
ab \up0 \expndtw-3\charscalex100 \u8216?\u8216?reason-\par\pard\qj \li1133\ri891
\sb2\sl-240\slmult0 \up0 \expndtw0\charscalex107 able\u8217?\u8217? suggestions,
useful either in the perioperative period as well as for \up0 \expndtw-4\charsc
alex100 fluid resuscitation. \par\pard\ql \li1133\sb0\sl-230\slmult0 \par\pard\q
l\li1133\sb99\sl-230\slmult0 \up0 \expndtw-2\charscalex100 Fluid restriction \pa
r\pard\qj \li1133\ri892\sb142\sl-240\slmult0\fi239 \up0 \expndtw-2\charscalex100
Despite a lack of convincing experimental evidence that iso-osmolar crystal-\li
ne \up0 \expndtw0\charscalex100 loids are detrimental, fluid restriction is stil
l widely practiced in patients with \line \up0 \expndtw0\charscalex100 mass lesi
ons, cerebral edema, and/or at risk for intracranial hypertension. The \line \up
0 \expndtw-1\charscalex100 only directly applicable data indicate that clinicall
y acceptable fluid restriction \line \up0 \expndtw0\charscalex102 has little eff
ect on edema formation; however, there is some \u8216?\u8216?logic\u8217?\u8217?
behind \line \up0 \expndtw0\charscalex106 modest fluid restriction. One of the
few human studies on fluid therapy in \line \up0 \expndtw-3\charscalex100 neuros
urgical patients demonstrated that patients given standard \u8216?\u8216?mainten
ance\u8217?\u8217? \line \up0 \expndtw0\charscalex102 amounts of intravenous flu
ids (eg, 2000 mL/day) in the postoperative period \line \up0 \expndtw0\charscale
x100 developed a progressive reduction in serum osmolality [2]. On the other han
d, \line \up0 \expndtw0\charscalex108 patients given half this volume over a per
iod of about \up0 \expndtw0\charscalex108 1 week showed a \par\pard\qj \li1133\r
i873\sb0\sl-240\slmult0 \up0 \expndtw-1\charscalex100 progressive increase in se
rum osmolality, which could account for dehydration \line \up0 \expndtw-2\charsc
alex100 of the brain (Fig. 2) [55]. Although no CNS-related parameters were meas
ured in \line \up0 \expndtw-1\charscalex100 this study, the results suggest that
the maintenance fluids used (0.45% NaCl in \line \up0 \expndtw-2\charscalex100
5% dextrose) contain excess-free water for the typical postoperative craniotomy
\line \up0 \expndtw0\charscalex105 patient. In this light, fluid restriction can
be viewed as \up0 \expndtw-4\charscalex100 \u8216?\u8216?preventing\u8217?\u821
7? hypo-\par\pard\ql \li1133\sb9\sl-230\slmult0 \up0 \expndtw-3\charscalex100 os
motically driven edema. This does not imply that even greater degrees of fluid \
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\pard\sb0\sl-240{\bkmkstart Pg10}{\bkmkend Pg10}\par\pard\li1049\sb0\sl-184\slmu
lt0\par\pard\li1049\sb0\sl-184\slmult0\par\pard\li1049\sb0\sl-184\slmult0\par\pa
rd\li1049\sb0\sl-184\slmult0\par\pard\li1049\sb112\sl-184\slmult0\fi0\tx2243 \up
0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs16 338\tab \up0 \expndtw-1\
charscalex100 C. Tommasino / Anesthesiology Clin N Am 20 (2002) 329-346\par\pard
\qj \li1049\sb0\sl-200\slmult0 \par\pard\qj\li1049\sb0\sl-200\slmult0 \par\pard\
qj\li1049\sb0\sl-200\slmult0 \par\pard\qj\li1049\sb0\sl-200\slmult0 \par\pard\qj
\li1049\sb0\sl-200\slmult0 \par\pard\qj\li1049\sb0\sl-200\slmult0 \par\pard\qj\l
i1049\sb0\sl-200\slmult0 \par\pard\qj\li1049\sb0\sl-200\slmult0 \par\pard\qj\li1
049\sb0\sl-200\slmult0 \par\pard\qj\li1049\sb0\sl-200\slmult0 \par\pard\qj\li104
9\sb0\sl-200\slmult0 \par\pard\qj\li1049\sb0\sl-200\slmult0 \par\pard\qj\li1049\
sb0\sl-200\slmult0 \par\pard\qj\li1049\sb0\sl-200\slmult0 \par\pard\qj\li1049\sb
0\sl-200\slmult0 \par\pard\qj\li1049\sb0\sl-200\slmult0 \par\pard\qj\li1049\sb0\
sl-200\slmult0 \par\pard\qj\li1049\sb0\sl-200\slmult0 \par\pard\qj\li1049\sb0\sl
-200\slmult0 \par\pard\qj\li1049\sb0\sl-200\slmult0 \par\pard\qj\li1049\sb0\sl-2
00\slmult0 \par\pard\qj\li1049\sb0\sl-200\slmult0 \par\pard\qj\li1049\sb0\sl-200
\slmult0 \par\pard\qj\li1049\sb0\sl-200\slmult0 \par\pard\qj\li1049\ri946\sb142\
sl-200\slmult0 \up0 \expndtw-3\charscalex100 Fig. 2. Effect of fluid restriction
(1 L/day) on serum osmolality in neurosurgical patients. (From Shenkin \up0 \ex
pndtw-3\charscalex100 HA, Benzier HO, Bouzarth W. Restricted fluid intake: ratio
nal management of the neurosurgical patient. \up0 \expndtw-3\charscalex100 J Neu
rosurg 1976;45:432 - 6; with permission by Lippincott Williams & Wilkins\ul0\nos
upersub\cf11\f12\fs16 D\ul0\nosupersub\cf9\f10\fs16 .) \par\pard\qj \li1049\sb0
\sl-240\slmult0 \par\pard\qj\li1049\ri976\sb7\sl-240\slmult0 \up0 \expndtw-1\cha
rscalex100 \ul0\nosupersub\cf4\f5\fs20 restriction are beneficial, or that the a
dministration of a fluid mixture that does \up0 \expndtw-3\charscalex100 not red
uce osmolality is detrimental. \par\pard\ql \li1049\sb0\sl-230\slmult0 \par\pard

\ql\li1049\sb19\sl-230\slmult0 \up0 \expndtw-3\charscalex100 Intraoperative volu

me replacement/resuscitation \par\pard\qj \li1049\ri977\sb142\sl-240\slmult0\fi2
39 \up0 \expndtw-3\charscalex100 As a general rule, intraoperative fluid adminis
tration should be given at a rate \line \up0 \expndtw-1\charscalex100 sufficient
to replace the urinary output and insensible losses. Table 3 illustrates \line
\up0 \expndtw-1\charscalex100 the intravascular volume expansion obtained with d
ifferent types of fluids. \par\pard\qj \li1049\ri915\sb0\sl-240\slmult0\fi239 \u
p0 \expndtw-1\charscalex100 The available data indicate that volume replacement/
expansion will have no \up0 \expndtw-3\charscalex100 effect on cerebral edema as
long as normal serum osmolality and oncotic pressure \up0 \expndtw0\charscalex1
00 are maintained, and as long as cerebral hydrostatic pressures are not markedl
y \up0 \expndtw0\charscalex100 increased (eg, due to true volume overload and el
evated right heart pressures). \up0 \expndtw0\charscalex100 Whether this is achi
eved with crystalloids or colloids seems irrelevant. Serum \up0 \expndtw0\charsc
alex100 osmolality should be checked repeatedly, with the goal being to maintain
this \up0 \expndtw-3\charscalex100 value either as constant or slightly increas
ed. \par\pard\ql \li1049\sb0\sl-184\slmult0 \par\pard\ql\li1049\sb103\sl-184\slm
ult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf9\f10\fs16 Table 3 \par\par
d\ql \li1049\sb16\sl-184\slmult0 \up0 \expndtw-3\charscalex100 Fluid replacement
and intravascular volume \par\pard\li1049\sb103\sl-184\slmult0\fi0\tx5595 \up0
\expndtw-1\charscalex100 Fluid infused\tab \up0 \expndtw-1\charscalex100 Intrava
scular volume increase\par\pard\li1049\sb95\sl-184\slmult0\fi0\tx5797 \up0 \expn
dtw-1\charscalex100 1 liter isotonic crystalloid\tab \up0 \expndtw-1\charscalex1
00 250 ml\par\pard\li1049\sb15\sl-184\slmult0\fi0\tx5797 \up0 \expndtw-1\charsca
lex100 1 liter 5% albumin\tab \up0 \expndtw-1\charscalex100 500 ml\par\pard\li10
49\sb16\sl-184\slmult0\fi0\tx5797 \up0 \expndtw-1\charscalex100 1 liter hetastar
ch\tab \up0 \expndtw-1\charscalex100 750 ml\par\pard\sect\sectd\fs24\paperw8640\
paperh12960\pard\sb0\sl-240{\bkmkstart Pg11}{\bkmkend Pg11}\par\pard\li2326\sb0\
sl-184\slmult0\par\pard\li2326\sb0\sl-184\slmult0\par\pard\li2326\sb0\sl-184\slm
ult0\par\pard\li2326\sb0\sl-184\slmult0\par\pard\li2326\sb112\sl-184\slmult0\fi0
\tx7350 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs16 C. Tommasino
/ Anesthesiology Clin N Am 20 (2002) 329-346\tab \up0 \expndtw-1\charscalex100 3
39\par\pard\qj \li1133\sb0\sl-238\slmult0 \par\pard\qj\li1133\ri877\sb13\sl-238\
slmult0\fi239 \up0 \expndtw0\charscalex105 \ul0\nosupersub\cf4\f5\fs20 Fluid adm
inistration that results in a reduction in osmolality should be \line \up0 \ex
pndtw-3\charscalex100 avoided. Small volumes of Lactated Ringer\u8217?s (not str
ictly iso-osmotic, measured \line \up0 \expndtw-3\charscalex100 osmolality 252 255 mOsm/kg) are unlikely to be detrimental, and can be safely \line \up0 \expn
dtw-2\charscalex100 used. If large volumes are needed (blood loss or other sourc
e of volume loss), a \line \up0 \expndtw-2\charscalex100 change to a more isoton
ic fluid is advisable. It is also important to remember that \line \up0 \expndtw
0\charscalex104 large and rapid infusion of 0.9% NaCl can induce a dose-dependen
t hyper-\line \up0 \expndtw-2\charscalex100 chloremic metabolic acidosis [64,65]
. Whether this acid-base abnormality is, in \line \up0 \expndtw-3\charscalex100
fact, harmful remains unclear, although animal studies suggest that hyperchlore\line \up0 \expndtw-2\charscalex100 mia causes renal vasoconstriction [66]. If l
arge volumes are needed, a combina-\line \up0 \expndtw-1\charscalex100 tion of i
sotonic crystalloids and colloids may be the best choice. The combined \line \up
0 \expndtw0\charscalex104 use of these fluids can avoid reductions both is serum
osmolality and COP. \line \up0 \expndtw-2\charscalex100 Hetastarch should be us
ed with caution due to coagulation factor VIII depletion \line \up0 \expndtw0\ch
arscalex103 and possible coagulation difficulties encountered with volumes \up0
\expndtw0\charscalex103 >1000 mL \par\pard\qj \li1133\ri868\sb1\sl-240\slmult0 \
up0 \expndtw-2\charscalex100 [67,68]. Pentastarch, a new formulation of hydrolyz
ed amylopectin, causes fewer \line \up0 \expndtw-3\charscalex100 effects on coag
ulation than hetastarch; it does not prolong the bleeding time, and \line \up0 \
expndtw0\charscalex100 has little effect on factor VIII [69]. Dextran 40 interfe
res with normal platelet \line \up0 \expndtw-1\charscalex100 function, and there
fore is not advisable for patients with intracranial pathology, \line \up0 \expn
dtw-2\charscalex100 other than to improve rheology, such as in ischemic brain di

seases. \par\pard\qj \li1133\ri831\sb0\sl-240\slmult0\fi239 \up0 \expndtw-1\char

scalex100 These recommendations should not be interpreted as \u8216?\u8216?give
all the isotonic -\line \up0 \expndtw-3\charscalex100 iso-oncotic fluid you like
.\u8217?\u8217? Volume overload can have detrimental effects on ICP, \up0 \expnd
tw-4\charscalex100 via increasing CBV or via hydrostatically driven edema format
ion. \par\pard\ql \li1133\sb0\sl-230\slmult0 \par\pard\ql\li1133\sb0\sl-230\slmu
lt0 \par\pard\ql\li1133\sb9\sl-230\slmult0 \up0 \expndtw-2\charscalex100 Postope
rative period \par\pard\qj \li1133\ri857\sb146\sl-236\slmult0\fi239 \up0 \expndt
w0\charscalex100 In the postoperative period, large fluid requirements should ce
ase. In such \line \up0 \expndtw-2\charscalex100 cases, the recommendations of S
henkin et al. [2] are probably reasonable, and we \line \up0 \expndtw-3\charscal
ex100 recommend periodic measurements of serum osmolality, particular if neurolo
gic \line \up0 \expndtw-3\charscalex100 status deteriorates. If cerebral edema d
oes develop, further restriction is unlikely \line \up0 \expndtw-2\charscalex100
to be of value, and can result in hypovolemia. Specific treatment with mannitol
, \line \up0 \expndtw-3\charscalex100 furosemide, and other drugs, combined with
normovolemia achieved with fluids \line \up0 \expndtw-3\charscalex100 that will
maintain the increased osmolality, appears to be reasonable. \par\pard\ql \li11
33\sb0\sl-230\slmult0 \par\pard\ql\li1133\sb0\sl-230\slmult0 \par\pard\ql\li1133
\sb9\sl-230\slmult0 \up0 \expndtw-2\charscalex100 Head injury \par\pard\qj \li11
33\ri892\sb142\sl-240\slmult0\fi239 \up0 \expndtw-2\charscalex100 Prompt restora
tion of systemic pressure is essential in head-injuried patients. \line \up0 \ex
pndtw0\charscalex100 In patients in whom multiple trauma complicates head injury
, no resuscitation \line \up0 \expndtw0\charscalex100 fluid has proven ideal [70
]. Hypotonic solutions (including Lactated Ringer\u8217?s \line \up0 \expndtw-3\
charscalex100 solutions) should be avoided, and therapy should rely on fluids wi
th osmolalities \line \up0 \expndtw0\charscalex103 around 300 mOsm/L. In cases o
f large-volume fluid administration, oncotic \line \up0 \expndtw0\charscalex105
pressure should be checked, and colloid solutions administered as needed. \line
\up0 \expndtw0\charscalex100 Hypertonic saline solutions have been used successf
ully to treat hypovolemia \line \up0 \expndtw-1\charscalex100 and intracranial h
ypertension in these patients [51 - 54,62]. Glucose-containing \line \up0 \expnd
tw0\charscalex100 solutions should be avoided, because hyperglycemia is associat
ed with poorer \line \up0 \expndtw-3\charscalex100 neurologic outcome in head-in
jured patients [37,39]. \par\pard\sect\sectd\fs24\paperw8640\paperh12960\pard\sb
0\sl-240{\bkmkstart Pg12}{\bkmkend Pg12}\par\pard\li1049\sb0\sl-184\slmult0\par\
pard\li1049\sb0\sl-184\slmult0\par\pard\li1049\sb0\sl-184\slmult0\par\pard\li104
9\sb0\sl-184\slmult0\par\pard\li1049\sb112\sl-184\slmult0\fi0\tx2243 \up0 \expnd
tw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs16 340\tab \up0 \expndtw-1\charscal
ex100 C. Tommasino / Anesthesiology Clin N Am 20 (2002) 329-346\par\pard\ql \li1
049\sb0\sl-230\slmult0 \par\pard\ql\li1049\sb27\sl-230\slmult0 \up0 \expndtw0\ch
arscalex100 \ul0\nosupersub\cf4\f5\fs20 Subarachnoid hemorrhage \par\pard\qj \li
1049\ri916\sb142\sl-240\slmult0\fi239 \up0 \expndtw-2\charscalex100 When treatin
g patients with subarachnoid hemorrhage two problems should be \up0 \expndtw-3\c
harscalex100 kept in mind: hyponatremia and hypovolemia. \par\pard\qj \li1049\ri
938\sb4\sl-236\slmult0\fi239 \up0 \expndtw0\charscalex105 In these patients, rel
ative hypovolemia develops very often. The cause is \line \up0 \expndtw0\charsca
lex108 multifactorial, and includes bed rest, negative nitrogen balance, decreas
ed \line \up0 \expndtw-2\charscalex100 erythropoiesis, iatrogenic blood loss, an
d dysregulation of the autonomic nervous \line \up0 \expndtw0\charscalex100 syst
em. Hyponatremia appears to develop as the result of a central salt-wasting \lin
e \up0 \expndtw0\charscalex110 syndrome, and the causative factor seems to be an
increased release of a \line \up0 \expndtw0\charscalex106 natriuretic factor fr
om the brain \up0 \expndtw0\charscalex106 [71]. Excessive renal excretion of sod
ium \par\pard\qj \li1049\ri918\sb1\sl-240\slmult0 \up0 \expndtw0\charscalex103 p
recedes the development of ischemic symptoms [72], and patients appear to \line
\up0 \expndtw-2\charscalex100 be at increased risk for delayed cerebral infarcti
on [73]. Hyponatremia should not \line \up0 \expndtw0\charscalex100 be a serious
concern if electrolytes and type of fluids administered are carefully \line \up
0 \expndtw-2\charscalex100 monitored. With the administration of a large volume

of isotonic crystalloids and \line \up0 \expndtw-2\charscalex100 restriction of

free water (hypotonic intravenous fluids and oral fluids) the severity \line \up
0 \expndtw0\charscalex102 of the fall in serum sodium concentration is ameliorat
ed, and usually does not \line \up0 \expndtw0\charscalex100 require further inte
rvention. If hyponatremia is more severe or significant cere-\line \up0 \expndtw
0\charscalex103 bral edema exists, the use of mild hypertonic fluids (1.25 or 1.
5% saline) and \line \up0 \expndtw0\charscalex100 strict avoidance of free water
administration are usually successful in reversing \line \up0 \expndtw-2\charsc
alex100 the hyponatremia. \par\pard\qj \li1049\ri916\sb3\sl-237\slmult0\fi239 \u
p0 \expndtw0\charscalex100 Fluid restriction should be abandoned, as it worsens
volume contraction and \line \up0 \expndtw0\charscalex100 exacerbates symptoms f
rom vasospasm. Hypertensive/hypervolemic therapy is \line \up0 \expndtw0\charsca
lex104 widely accepted to prevent/treat symptomatic cerebral vasospasm [74]. Thi
s \line \up0 \expndtw0\charscalex100 therapeutic treatment, however, has never b
een carefully studied (control group \line \up0 \expndtw-3\charscalex100 with no
therapy, or other treatments), and it is not clear whether hypertension and/ \l
ine \up0 \expndtw-1\charscalex100 or hypervolemia is the critical factor. Volume
loading is usually performed with \line \up0 \expndtw0\charscalex107 colloids,
and great care is required to avoid reduction in serum osmolality, \line \up0 \e
xpndtw0\charscalex105 because this will increase brain water content in ischemic
as well as normal \line \up0 \expndtw-2\charscalex100 cerebral regions [75]. \p
ar\pard\ql \li1049\sb0\sl-230\slmult0 \par\pard\ql\li1049\sb59\sl-230\slmult0 \u
p0 \expndtw-3\charscalex100 Ischemic injury \par\pard\qj \li1049\ri976\sb142\sl240\slmult0\fi239 \up0 \expndtw0\charscalex106 The one situation where hemodilut
ion may be beneficial is in the period \line \up0 \expndtw0\charscalex102 immedi
ately during/after a focal cerebral ischemic event. Several studies have \line \
up0 \expndtw0\charscalex102 shown that regional O\ul0\sub\cf8\f9\fs21 2\ul0\nosu
persub\cf4\f5\fs20 delivery in this situation may be increased (or at least \l
ine \up0 \expndtw-1\charscalex100 better maintained) in the face of modest hemod
ilution (Hct \up0 \expndtw-2\charscalex100 30%), and animal \par\pard\qj \li1049
\ri976\sb0\sl-240\slmult0 \up0 \expndtw0\charscalex105 studies demonstrate impro
vement in CBF and some reductions in infarction \line \up0 \expndtw0\charscalex1
03 volumes [20,76]. Unfortunately, several trials have failed to demonstrate any
\line \up0 \expndtw0\charscalex100 benefit of hemodilution in stroke, except in
polycythemic patients [77 - 80]. \par\pard\ql \li1049\sb0\sl-230\slmult0 \par\p
ard\ql\li1049\sb39\sl-230\slmult0 \up0 \expndtw-1\charscalex100 Spinal cord inju
ry \par\pard\qj \li1049\ri924\sb142\sl-240\slmult0\fi239 \up0 \expndtw-2\charsca
lex100 Although the literature lacks specific studies on the spinal cord effects
of fluid \line \up0 \expndtw0\charscalex100 therapy, in patients with acute spi
nal cord injury, a prevalence of hyponatremia \line \up0 \expndtw0\charscalex100
much higher than in the general medical or surgical patient population has been
\line \up0 \expndtw-2\charscalex100 reported [81]. This study did not elucidate
the ethiology of hyponatremia, and did \par\pard\sect\sectd\fs24\paperw8640\pap
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fa37af87ff00f8077dff00c9f401f60515f1ff00fc3017ec6bff0046f5f0ff00ff0000efbff93e8f
f8602fd8d7fe8debe1ff00fe01df7ff27d007d81457c7fff000c05fb1aff00d1bd7c3fff00c03bef
fe4fa3fe180bf635ff00a37af87fff008077dffc9f401f60515f1fff00c3017ec6bff46f5f0fff00
f00efbff0093e8ff008602fd8d7fe8debe1fff00e01df7ff0027d007d81457c7ff00f0c05fb1affd
1bd7c3ff00fc03beff00e4fa3fe180bf635ffa37af87ff00f8077dff00c9f401f60515f1ff00fc30
17ec6bff0046f5f0ff00ff0000efbff93e8ff8602fd8d7fe8debe1ff00fe01df7ff27d007d81457c
7fff000c05fb1aff00d1bd7c3fff00c03beffe4fa3fe180bf635ff00a37af87fff008077dffc9f40
1f60515f1fff00c3017ec6bff46f5f0fff00f00efbff0093e8ff008602fd8d7fe8debe1fff00e01d
f7ff0027d007d81457c7ff00f0c05fb1affd1bd7c3ff00fc03beff00e4fa3fe180bf635ffa37af87
ff00f8077dff00c9f401f60515f1ff00fc3017ec6bff0046f5f0ff00ff0000efbff93e8ff8602fd8
d7fe8debe1ff00fe01df7ff27d007d81457c7fff000c05fb1aff00d1bd7c3fff00c03beffe4fa3fe
180bf635ff00a37af87fff008077dffc9f401f60515f1fff00c3017ec6bff46f5f0fff00f00efbff
0093e8ff008602fd8d7fe8debe1fff00e01df7ff0027d007d81457c7ff00f0c05fb1affd1bd7c3ff
00fc03beff00e4fa3fe180bf635ffa37af87ff00f8077dff00c9f401f60515f1ff00fc3017ec6bff
0046f5f0ff00ff0000efbff93e8ff8602fd8d7fe8debe1ff00fe01df7ff27d007d81457c7fff000c
05fb1aff00d1bd7c3fff00c03beffe4fa3fe180bf635ff00a37af87fff008077dffc9f401f60515f
1fff00c3017ec6bff46f5f0fff00f00efbff0093e8ff008602fd8d7fe8debe1fff00e01df7ff0027
d007d81457c7ff00f0c05fb1affd1bd7c3ff00fc03beff00e4fa3fe180bf635ffa37af87ff00f807
7dff00c9f401f60515f1ff00fc3017ec6bff0046f5f0ff00ff0000efbff93e8ff8602fd8d7fe8deb
e1ff00fe01df7ff27d007d81457c7fff000c05fb1aff00d1bd7c3fff00c03beffe4fa3fe180bf635
ff00a37af87fff008077dffc9f401f60515f1fff00c3017ec6bff46f5f0fff00f00efbff0093e8ff
008602fd8d7fe8debe1fff00e01df7ff0027d007d81457c7ff00f0c05fb1affd1bd7c3ff00fc03be
ff00e4fa3fe180bf635ffa37af87ff00f8077dff00c9f401f60515f1ff00fc3017ec6bff0046f5f0
ff00ff0000efbff93e8ff8602fd8d7fe8debe1ff00fe01df7ff27d007d81457c7fff000c05fb1aff
00d1bd7c3fff00c03beffe4fa3fe180bf635ff00a37af87fff008077dffc9f401f60515f1fff00c3
017ec6bff46f5f0fff00f00efbff0093e8ff008602fd8d7fe8debe1fff00e01df7ff0027d007d814
57c7ff00f0c05fb1affd1bd7c3ff00fc03beff00e4fa3fe180bf635ffa37af87ff00f8077dff00c9
f401f60515f1ff00fc3017ec6bff0046f5f0ff00ff0000efbff93e8ff8602fd8d7fe8debe1ff00fe
01df7ff27d007d81457c7fff000c05fb1aff00d1bd7c3fff00c03beffe4fa3fe180bf635ff00a37a
f87fff008077dffc9f401f60515f1fff00c3017ec6bff46f5f0fff00f00efbff0093e8ff008602fd
8d7fe8debe1fff00e01df7ff0027d007d81457c7ff00f0c05fb1affd1bd7c3ff00fc03beff00e4fa
3fe180bf635ffa37af87ff00f8077dff00c9f401f60515f1ff00fc3017ec6bff0046f5f0ff00ff00
00efbff93e8ff8602fd8d7fe8debe1ff00fe01df7ff27d007d81457c7fff000c05fb1aff00d1bd7c
3fff00c03beffe4fafa2be1efc38f037c28f0b597827e1cf86b4df08f8534d9af6e2c742d25248ec
6da6d46ee5bebd923496495c35cddcf2cf265c83248c40038a00ffd9}}}}}
\pard\sb0\sl-240{\bkmkstart Pg13}{\bkmkend Pg13}\par\pard\li2326\sb0\sl-184\slmu
lt0\par\pard\li2326\sb0\sl-184\slmult0\par\pard\li2326\sb0\sl-184\slmult0\par\pa
rd\li2326\sb0\sl-184\slmult0\par\pard\li2326\sb112\sl-184\slmult0\fi0\tx7350 \up
0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs16 C. Tommasino / Anesthesi
ology Clin N Am 20 (2002) 329-346\tab \up0 \expndtw-1\charscalex100 341\par\pard
\qj \li1133\sb0\sl-236\slmult0 \par\pard\qj\li1133\ri840\sb17\sl-236\slmult0 \up
0 \expndtw-2\charscalex100 \ul0\nosupersub\cf4\f5\fs20 not consider type and amo
unt of fluids administered. However, the occurrence of \line \up0 \expndtw-2\cha
rscalex100 hyponatremia after acute spinal cord injury stresses the importance o
f appropriate \line \up0 \expndtw0\charscalex107 fluid management in these patie
nts, mostly to prevent the consequences of \line \up0 \expndtw0\charscalex102 re
duced plasma osmolality, which might exacerbate spinal cord edema. Labo-\line \u
p0 \expndtw-1\charscalex100 ratory researches have demonstrated that hypertonic
saline decreases spinal cord \line \up0 \expndtw-1\charscalex100 water content [
13], and may provide protection after mechanical injury [82]. \par\pard\ql \li11
33\sb0\sl-230\slmult0 \par\pard\ql\li1133\sb0\sl-230\slmult0 \par\pard\ql\li1133
\sb29\sl-230\slmult0 \up0 \expndtw0\charscalex105 Water and electrolytes disturb
ances \par\pard\ql \li1133\sb0\sl-230\slmult0 \par\pard\ql\li1133\sb40\sl-230\sl
mult0 \up0 \expndtw-1\charscalex100 Diabetes insipidus \par\pard\qj \li1133\ri89
2\sb142\sl-240\slmult0\fi239 \up0 \expndtw0\charscalex100 Diabetes insipidus (DI

) is a common sequelae of pituitary and hypothalamic \line \up0 \expndtw0\charsc

alex100 lesions, but it can also occur after head trauma or intracranial surgery
. Patients \line \up0 \expndtw0\charscalex100 with brain death also commonly dev
elop DI, and it should be remembered that \line \up0 \expndtw0\charscalex105 DI
may also occur during phenytoin use, in alcohol intoxication, and bacte-\line \u
p0 \expndtw-2\charscalex100 rial meningitis. \par\pard\qj \li1133\ri832\sb4\sl-2
36\slmult0\fi239 \up0 \expndtw-2\charscalex100 DI is a metabolic disorder due to
a decreased secretion of antidiuretic hormone \line \up0 \expndtw0\charscalex10
0 (ADH), resulting in failure of tubular reabsorbtion of water. Polyuria (>30 mL
/ \line \up0 \expndtw0\charscalex102 kg/h or, in an adult, >200 mL/h), progressi
ve dehydration, and hypernatremia \line \up0 \expndtw0\charscalex108 subsequentl
y occur. Diabetes insipidus is present when the urine output is \line \up0 \expn
dtw-3\charscalex100 excessive, the urine osmolality is inappropriately low relat
ive to serum osmolality \line \up0 \expndtw-3\charscalex100 (above normal becaus
e of water loss), and the urine specific gravity is lower than \par\pard\ql \li1
133\sb9\sl-230\slmult0\tx1649 \up0 \expndtw-2\charscalex100 1.002 \tab \up0 \exp
ndtw-3\charscalex100 (Table 4). \par\pard\qj \li1133\sb0\sl-240\slmult0 \par\par
d\qj\li1133\ri892\sb2\sl-240\slmult0 \up0 \expndtw0\charscalex103 Management of
DI requires careful balancing of intake and output, mostly to \up0 \expndtw-1\ch
arscalex100 avoid fluid overload \par\pard\qj \li1133\ri832\sb0\sl-240\slmult0\f
i239 \up0 \expndtw0\charscalex100 Each hour the patient should receive maintenan
ce fluids plus three quarters \line \up0 \expndtw-3\charscalex100 of the previou
s hour\u8217?s urine output, or plus the previous hour\u8217?s urine output minu
s \par\pard\ql \li1133\sb9\sl-230\slmult0 \up0 \expndtw-2\charscalex100 50 mL. H
alf-normal saline and D5W are commonly used as replacement fluids, \par\pard\ql
\li1133\sb0\sl-184\slmult0 \par\pard\ql\li1133\sb104\sl-184\slmult0 \up0 \expndt
w-2\charscalex100 \ul0\nosupersub\cf9\f10\fs16 Table 4 \par\pard\ql \li1133\sb16
\sl-184\slmult0 \up0 \expndtw-2\charscalex100 Principal water-electrolytes disor
ders \par\pard\li1133\sb93\sl-184\slmult0\fi2416\tx4970\tx6529 \up0 \expndtw-1\c
harscalex100 DI\tab \up0 \expndtw-1\charscalex100 SIADH\tab \up0 \expndtw-1\char
scalex100 CSWS\par\pard\li1133\sb95\sl-184\slmult0\fi0\tx3550\tx4970\tx6529 \up0
\expndtw-1\charscalex100 Etiology\tab \up0 \expndtw-1\charscalex100 Reduced sec
retion\tab \up0 \expndtw-1\charscalex100 Excessive release\tab \up0 \expndtw-1\c
harscalex100 Release of brain\par\pard\li1133\sb14\sl-184\slmult0\fi2416\tx4970\
tx6529 \up0 \expndtw-1\charscalex100 of ADH\tab \up0 \expndtw-1\charscalex100 of
ADH\tab \up0 \expndtw-1\charscalex100 natriuretic factor\par\pard\li1133\sb16\s
l-184\slmult0\fi0\tx2200\tx3550 \up0 \expndtw-1\charscalex100 Urine\tab \up0 \ex
pndtw-1\charscalex100 Output\tab \up0 \expndtw-1\charscalex100 > 30 ml/kg/h\par\
pard\li1133\sb16\sl-184\slmult0\fi1066\tx3550 \up0 \expndtw-1\charscalex100 spec
ific gravity\tab \up0 \expndtw-1\charscalex100 < 1.002\par\pard\li1133\sb15\sl-1
84\slmult0\fi1066\tx3550\tx4970\tx6529 \up0 \expndtw-1\charscalex100 Sodium\tab
\up0 \expndtw-1\charscalex100 < 15 mEq/l\tab \up0 \expndtw-1\charscalex100 > 20
mEq/l\tab \up0 \expndtw-1\charscalex100 > 50 mEq/l\par\pard\li1133\sb15\sl-184\s
lmult0\fi1066\tx3550\tx4970\tx6529 \up0 \expndtw-1\charscalex100 Osmolality vs.\
tab \up0 \expndtw-1\charscalex100 Lower\tab \up0 \expndtw-1\charscalex100 Higher
\tab \up0 \expndtw-1\charscalex100 Higher\par\pard\li1133\sb15\sl-184\slmult0\fi
1066 \up0 \expndtw-1\charscalex100 serum osmolality\par\pard\li1133\sb16\sl-184\
slmult0\fi0\tx2200\tx3550\tx4970\tx6529 \up0 \expndtw-1\charscalex100 Serum\tab
\up0 \expndtw-1\charscalex100 Sodium\tab \up0 \expndtw-1\charscalex100 Hypernatr
emia\tab \up0 \expndtw-1\charscalex100 Hyponatremia\tab \up0 \expndtw-1\charscal
ex100 Hyponatremia\par\pard\li1133\sb15\sl-184\slmult0\fi1066\tx3550\tx4970 \up0
\expndtw-1\charscalex100 Osmolality\tab \up0 \expndtw-1\charscalex100 Hyperosmo
lality\tab \up0 \expndtw-1\charscalex100 Hypoosmolality\par\pard\li1133\sb15\sl184\slmult0\fi0\tx3550\tx4970 \up0 \expndtw-1\charscalex100 Intravascular\tab \u
p0 \expndtw-1\charscalex100 Reduced\tab \up0 \expndtw-1\charscalex100 Normal or
increased
Reduced\par\pard\ql \li1293\sb7\sl-184\slmult0 \up0 \expndtw-2\char
scalex100 volume \par\pard\qj \li1133\ri923\sb63\sl-200\slmult0 \up0 \expndtw0\c
harscalex100 Abbreviations: ADH, antidiuretic hormone; CSWS, celebral salt-wasti
ng syndrome; DI, Diabetes \up0 \expndtw-2\charscalex100 insipidus; SIADH, syndro
me of inappropriate antidiuretic hormone secretion. \par\pard\sect\sectd\fs24\pa

perw8640\paperh12960\pard\sb0\sl-240{\bkmkstart Pg14}{\bkmkend Pg14}\par\pard\li

1049\sb0\sl-184\slmult0\par\pard\li1049\sb0\sl-184\slmult0\par\pard\li1049\sb0\s
l-184\slmult0\par\pard\li1049\sb0\sl-184\slmult0\par\pard\li1049\sb112\sl-184\sl
mult0\fi0\tx2243 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f10\fs16 342\
tab \up0 \expndtw-1\charscalex100 C. Tommasino / Anesthesiology Clin N Am 20 (20
02) 329-346\par\pard\qj \li1049\sb0\sl-236\slmult0 \par\pard\qj\li1049\ri915\sb1
7\sl-236\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf4\f5\fs20 with
appropriate potassium supplementation. Serum sodium, potassium, and gly\up0 \exp
ndtw-2\charscalex100 cemic values should be checked frequently. In the presence
of urine output higher \up0 \expndtw0\charscalex105 than 300 mL/h, at least for
2 hours, it is now standard practice to administer \up0 \expndtw0\charscalex100
aqueous vasopressin [5-10 IU, intramuscularly (i.m.), or subcutaneously (s.c.),
\up0 \expndtw0\charscalex108 q6h]orthesyntheticanalogofADH,desmopressinacetate(D
DAVP:0.5-2mg, \up0 \expndtw-2\charscalex100 intravenously (i.v.), q 8 h; or by n
asal inhalation, 10 - 20 mg). \par\pard\ql \li1049\sb0\sl-230\slmult0 \par\pard\
ql\li1049\sb59\sl-230\slmult0 \up0 \expndtw-1\charscalex100 Syndrome of inapprop
riate antidiuretic hormone secretion \par\pard\qj \li1049\ri976\sb142\sl-240\slm
ult0\fi239 \up0 \expndtw0\charscalex105 Various cerebral pathologic processes (m
ostly head trauma) can result in \up0 \expndtw0\charscalex102 excessive release
of ADH, which causes continued renal excretion of sodium, \up0 \expndtw-1\charsc
alex100 despite hyponatremia and associated hypo-osmolality. Urine osmolality is
there\up0 \expndtw0\charscalex100 fore high, relative to serum osmolality (Tabl
e 4). It should be remembered that \up0 \expndtw-1\charscalex100 the syndrome of
inappropriate antidiuretic hormone secretion (SIADH) can also \up0 \expndtw0\ch
arscalex100 be the result of overadministration of free water (D5W) in patients
who cannot \up0 \expndtw0\charscalex100 excrete free water, because of excess of
ADH. \par\pard\ql \li1049\sb0\sl-230\slmult0 \par\pard\ql\li1049\sb59\sl-230\sl
mult0 \up0 \expndtw-3\charscalex100 Management \par\pard\qj \li1049\ri976\sb2\sl
-240\slmult0\fi239 \up0 \expndtw0\charscalex105 The mainstay of treatment of SIA
DH is fluid restriction, usually to about \line \up0 \expndtw0\charscalex100 100
0 mL/24 h of an iso-osmolar solution. If hyponatremia is severe (lower than \lin
e \up0 \expndtw0\charscalex100 110 - 115 mEq/L) administration of hypertonic (3
- 5%) saline and furosemide \line \up0 \expndtw0\charscalex103 may be appropriat
e. Great care is required to avoid rapid correction of severe \line \up0 \expndt
w0\charscalex103 hyponatremia. A good rule is to restore serum sodium levels at
a rate of about \par\pard\ql \li1049\sb9\sl-230\slmult0 \up0 \expndtw-1\charscal
ex100 2 mEq/L/h. \par\pard\ql \li1049\sb0\sl-230\slmult0 \par\pard\ql\li1049\sb6
0\sl-230\slmult0 \up0 \expndtw-1\charscalex100 Cerebral salt-wasting syndrome \p
ar\pard\qj \li1049\ri976\sb150\sl-230\slmult0\fi239 \up0 \expndtw0\charscalex102
Cerebral salt-wasting syndrome (CSWS) is frequently seen in patients with \up0
\expndtw0\charscalex100 subarachnoid hemorrhage, and is characterized by hyponat
remia, volume con\up0 \expndtw-1\charscalex100 traction, and high urine sodium c
oncentration (Table 4). \par\pard\ql \li1049\sb0\sl-230\slmult0 \par\pard\ql\li1
049\sb60\sl-230\slmult0 \up0 \expndtw-3\charscalex100 Management \par\pard\qj \l
i1049\ri917\sb2\sl-240\slmult0\fi239 \up0 \expndtw-2\charscalex100 The therapy i
s to reestablish normovolemia with the administration of sodium\up0 \expndtw-3\c
harscalex100 containing solutions. \par\pard\qj \li1049\ri963\sb0\sl-240\slmult0
\fi239 \up0 \expndtw0\charscalex100 The distinction between SIADH and CSWS is ve
ry important, because fluid \up0 \expndtw-2\charscalex100 treatment of theses tw
o syndromes is quite different (fluid restriction versus fluid \up0 \expndtw0\ch
arscalex107 infusion). It should be stressed that in patients with SAH, in whom
normo/ \up0 \expndtw0\charscalex100 hypervolemia is advocated, fluid restriction
(that is, further volume contraction) \up0 \expndtw-1\charscalex100 may be espe
cially deleterious. \par\pard\ql \li1049\sb0\sl-230\slmult0 \par\pard\ql\li1049\
sb59\sl-230\slmult0 \up0 \expndtw-3\charscalex100 Conclusion \par\pard\qj \li104
9\ri975\sb2\sl-240\slmult0\fi239 \up0 \expndtw0\charscalex106 Fluid management h
as progressed rapidly in the last 3 decades. Current \line \up0 \expndtw0\charsc
alex107 regimens are sufficient to restore systemic perfusion in the majority of
pa-\line \up0 \expndtw0\charscalex107 tients undergoing surgery. However, impor
tant questions still remain to be \line \up0 \expndtw0\charscalex107 answered re

garding the frequency of complications of current fluid therapy \par\pard\sect\s

ectd\fs24\paperw8640\paperh12960\pard\sb0\sl-240{\bkmkstart Pg15}{\bkmkend Pg15}
\par\pard\li2326\sb0\sl-184\slmult0\par\pard\li2326\sb0\sl-184\slmult0\par\pard\
li2326\sb0\sl-184\slmult0\par\pard\li2326\sb0\sl-184\slmult0\par\pard\li2326\sb1
12\sl-184\slmult0\fi0\tx7350 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf9\f
10\fs16 C. Tommasino / Anesthesiology Clin N Am 20 (2002) 329-346\tab \up0 \expn
dtw-1\charscalex100 343\par\pard\qj \li1133\sb0\sl-240\slmult0 \par\pard\qj\li11
33\ri886\sb9\sl-240\slmult0 \up0 \expndtw0\charscalex103 \ul0\nosupersub\cf4\f5\
fs20 and the comparative advantages of different fluid formulations in a variety
of \up0 \expndtw-3\charscalex100 clinical circumstances. \par\pard\qj \li1133\r
i851\sb5\sl-235\slmult0\fi239 \up0 \expndtw-1\charscalex100 As neuroanesthesiolo
gists/intensivists, we should always remember that we \up0 \expndtw0\charscalex1
04 treat patients and not only brains. Thus, with the exception of patients with
\up0 \expndtw-2\charscalex100 SIADH, the old dogma that states that patients wi
th intracranial pathology should \up0 \expndtw-3\charscalex100 be kept \u8216?\u
8216?dry\u8217?\u8217? (\u8216?\u8216?run them dry\u8217?\u8217?) should be aban
doned, and be replaced by \u8216?\u8216?run \up0 \expndtw-4\charscalex100 them i
sovolemic, isotonic, and isooncotic.\u8217?\u8217? \par\pard\ql \li1133\sb0\sl-2
30\slmult0 \par\pard\ql\li1133\sb0\sl-230\slmult0 \par\pard\ql\li1133\sb50\sl-23
0\slmult0 \up0 \expndtw-1\charscalex100 References \par\pard\ql \li1213\sb0\sl-1
84\slmult0 \par\pard\ql\li1213\sb4\sl-184\slmult0\tx1475 \up0 \expndtw-3\charsca
lex100 \ul0\nosupersub\cf9\f10\fs16 [1] \tab \up0 \expndtw0\charscalex100 Tommas
ino C. Fluid management. In: Newfield P, Cottrell JE, editors. Handbook of neuro
-\par\pard\ql \li1475\sb16\sl-184\slmult0 \up0 \expndtw-2\charscalex100 anesthes
ia. 2\ul0\super\cf10\f11\fs16 nd\ul0\nosupersub\cf9\f10\fs16 edition. New York:
Lippincott-Williams and Wilkins; 1999. p. 368 - 84. \par\pard\ql \li1213\sb16\s
l-184\slmult0\tx1476 \up0 \expndtw-3\charscalex100 [2] \tab \up0 \expndtw0\chars
calex100 Shenkin HA, Benzier HO, Bouzarth W. Restricted fluid intake: rational m
anagement of the \par\pard\ql \li1476\sb16\sl-184\slmult0 \up0 \expndtw-3\charsc
alex100 neurosurgical patient. J Neurosurg 1976;45:432 - 6. \par\pard\ql \li1213
\sb16\sl-184\slmult0\tx1475 \up0 \expndtw-3\charscalex100 [3] \tab \up0 \expndtw
-2\charscalex100 Chestnut RM, Marshall LF, Klauber MR, et al. The role of second
ary brain injury in determining \par\pard\ql \li1475\sb16\sl-184\slmult0 \up0 \e
xpndtw-3\charscalex100 outcome from severe head injury. J Trauma 1993;34:216 - 2
2. \par\pard\li1213\sb25\sl-184\slmult0\fi0\tx1475 \up0 \expndtw-5\charscalex100
[4]\tab \up0 \expndtw-1\charscalex100 Starling EH. In: Schaefer E, editor. Text
book of physiology. London: Caxton; 1898. p. 285 - 311.\par\pard\li1213\sb16\sl184\slmult0\fi0\tx1475 \up0 \expndtw-5\charscalex100 [5]\tab \up0 \expndtw-1\cha
rscalex100 Fenstermacher JD, Johnson JA. Filtration and reflection coefficients
of the rabbit blood - brain\par\pard\li1213\sb15\sl-184\slmult0\fi261 \up0 \expn
dtw-2\charscalex100 barrier. Am J Physiol 1966;211:341 - 6.\par\pard\ql \li1213\
sb8\sl-184\slmult0\tx1475 \up0 \expndtw-3\charscalex100 [6] \tab \up0 \expndtw-1
\charscalex100 Hindman BJ, Funatsu N, Cheng DCH, et al. Differential effect of o
ncotic pressure on cerebral \par\pard\qj \li1475\ri904\sb3\sl-200\slmult0 \up0 \
expndtw0\charscalex102 and extracerebral water content during cardiopulmonary by
pass in rabbits. Anesthesiology \up0 \expndtw-3\charscalex100 1990;73:951 - 7. \
par\pard\ql \li1213\sb14\sl-184\slmult0\tx1475 \up0 \expndtw-3\charscalex100 [7]
\tab \up0 \expndtw-2\charscalex100 Tommasino C, Moore S, Todd MM. Cerebral effe
cts of isovolemic hemodilution with crystalloid \par\pard\ql \li1475\sb16\sl-184
\slmult0 \up0 \expndtw-2\charscalex100 or colloid solutions in normal rabbits. C
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