Circulatory volume expansion therapy for aneurysmal subarachnoid haemorrhage

  • Review
  • Intervention

Authors


Abstract

Background

Secondary ischaemia is a frequent complication after aneurysmal subarachnoid haemorrhage (SAH), and responsible for a substantial proportion of patients with poor outcome after SAH. The cause of secondary ischaemia is unknown, but hypovolaemia and fluid restriction are important risk factors. Therefore, volume expansion therapy (hypervolaemia) is frequently used in patients with SAH to prevent or treat secondary ischaemia.

Objectives

To determine the effectiveness of volume expansion therapy for improving outcome in patients with aneurysmal SAH.

Search methods

We searched the Cochrane Stroke Group Trials Register (last searched September 2003). In addition we searched MEDLINE (1966 to January 2004) and EMBASE (1980 to January 2004) and contacted trialists to identify further published and unpublished studies.

Selection criteria

All randomised controlled trials of volume expansion therapy in patients with aneurysmal SAH. We also sought controlled trials based on consecutive groups of patients quasi-randomly allocated to treatment or control group and included these in the analysis if the two groups were well comparable with regard to major prognostic factors.

Data collection and analysis

Two reviewers independently extracted the data and assessed trial quality. Trialists were contacted to obtain missing information.

Main results

We identified three trials. One truly randomised trial and one quasi-randomised trial with comparable baseline characteristics for both groups were included in the analyses. Volume expansion therapy did not improve outcome (Relative Risk (RR) 1.0; 95% Confidence Interval (CI) 0.5 to 2.2), nor the occurrence of secondary ischaemia (RR 1.1; 95% CI 0.5 to 2.2). Hypervolaemia tended to increase the rate of complications (RR 1.8; 95% CI 0.9 to 3.7) In another quasi-randomised trial, outcome assessment was done only at the day of operation (7 to 10 days after SAH). In the period before operation, treatment resulted in a reduction of secondary ischaemia (RR 0.33; 95% CI 0.11 to 0.99) and case fatality (RR 0.20; 95% CI 0.07 to 1.2).

Authors' conclusions

The effects of volume expansion therapy have been studied properly in only two trials of patients with aneurysmal SAH, with very small numbers. At present, there is no sound evidence for the use of volume expansion therapy in patients with aneurysmal SAH.

摘要

背景

循環容積擴張治療用於動脈瘤性蜘蛛網膜下腔出血

次發性的缺血是動脈瘤性蜘蛛網膜下腔出血(SAH)常見的併發症,並且是一定比例的病人在SAH後產生不良預後的原因。次發性缺血的原因不明,但低容積血症以及體液的限制是重要的危險因子。因此,容積擴張治療(高容積血症)經常被用於SAH的病人以預防或治療次發性缺血。

目標

為了確定容積擴張治療對於改善動脈瘤性SAH病人預後的效果。

搜尋策略

我們搜尋Cochrane Stroke Group Trials Register(搜尋至2003年9月)。此外我們也搜尋MEDLINE(1966年至2004年1月)和EMBASE(1980年至2004年1月),並且聯絡試驗者以確認更多已發表和未發表的研究。

選擇標準

容積擴張治療用於動脈瘤性SAH病人的所有隨機對照試驗(randomised controlled trial)。我們同時尋找的對照試驗是基於連續幾組的病人被半隨機(quasirandom)地分派到治療與對照組的;如果這兩組病人在主要的預後因子方面是很相稱的,我們則在分析中納入這些試驗。

資料收集與分析

兩位檢閱人各自篩選資料並評估試驗品質。我們聯絡試驗者以獲得更多遺漏的資訊。

主要結論

我們確認了3個試驗。一個真正的隨機試驗以及一個兩組基本特徵相稱的半隨機試驗,被納入分析。容積擴張治療並不能改善預後(相對風險(Relative Risk, RR) 1.0; 95% CI 0.5 to 2.2),或是次發性缺血的發生(RR 1.1; 95% CI 0.5 to 2.2)。高容積血症傾向會增加併發症的機率(RR 1.8; 95% CI 0.9 to 3.7)。在另一個半隨機試驗裡,預後評估只做在手術的那一天(SAH後7到10天)。在手術前的期間,治療結果減少了次發性缺血的產生(RR 0.33; 95% CI 0.11 to 0.99)以及個案死亡率(RR 0.20; 95% CI 0.07 to 1.2)。

作者結論

容積擴張治療的效用只在兩個動脈瘤性SAH病人的試驗被研究過,而且人數很少。現在來說,並沒有可靠的證據支持容積擴張治療在動脈瘤性SAH的病人身上使用。

翻譯人

本摘要由奇美醫院陳軾正翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

沒有證據顯示給予大量的液體對於蜘蛛網膜下腔出血的病人是有益的。蜘蛛網膜下腔出血是好發於相對年輕族群的一種中風型態(大多介於40到60歲間)。次發性缺血是蜘蛛網膜下腔出血後導致不良預後的一個重要因子(半數的此種病人在出血後的一個月內死亡)。這種的缺血發生於出血後的4到10天(因此是次發性),也許是因為尿液量的增加導致體液流失而造成。這篇回顧並顯示沒有證據支持給予更多的液體,為了不只彌補體液的喪失,而且增加體內的水份量。

Plain language summary

Circulatory volume expansion therapy for aneurysmal subarachnoid haemorrhage

There is no evidence that administration of large volume of fluids is beneficial in patients with subarachnoid haemorrhage. Subarachnoid haemorrhage is a subset of stroke that occurs frequently in relatively young persons (mostly 40 to 60 years of age). Secondary ischaemia is an important contributor to poor outcome after a subarachnoid haemorrhage (half the patients die within a month after the haemorrhage). This type of ischaemia occurs 4 to 10 days (hence: secondary) after the haemorrhage, possibly due to fluid loss through increased urinary production. This review shows that there is no evidence to support giving additional fluids to not only compensate for the loss of fluid but also to increase the amount of fluid in the body.

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