Optimizing Intraoperative Fluid Replacement for Patients Receiving Mannitol During Neurosurgical Procedures: A Quality Improvement Initiative

Abstract

Patients undergoing craniotomy are at increased risk of intravascular volume changes due to the use of mannitol. This quality improvement project was conducted to implement a standardized goal-directed fluid therapy (GDFT) protocol using a dynamic physiologic measure in an attempt to maintain euvolemia in patients undergoing craniotomy with mannitol administration. An evidence-based GDFT protocol was integrated into an existing neurosurgical protocol. Anesthesia providers were asked to implement the protocol in patients who met the screening criteria. A preimplementation and postimplementation record review was conducted to compare outcomes of the intervention with standard practice. Primary outcomes included intensive care unit (ICU) length of stay (LOS), hospital LOS, serum lactate levels, and the total amounts of intraoperative crystalloid and colloid administered between the preimplementation and postimplementation groups. Of 95 patients who met the screening criteria, 51 (54%) had full protocol compliance. There was no significant difference between groups in ICU LOS (P=.700), hospital LOS (P=.948), serum lactate levels (P=.484), or the total amount of intraoperative crystalloid administered (P=.122). The postimplementation group had significantly more colloid administered than the preimplementation group (P=.004). A lack of provider compliance with the protocol may have affected these results. Further refined quality improvement cycles are warranted.

Keywords: Craniotomy; dynamic parameters; goal-directed fluid therapy; mannitol; stroke volume variation.