Cardiac output-guided vs. mean arterial pressure-guided hemodynamic management in craniotomy patients with cardiovascular disease: a randomized trial

We tested the primary hypothesis that cardiac output (CO)-guided versus mean arterial pressure (MAP)-guided hemodynamic management reduces the fraction of patients with 90-day Glasgow Outcome scores ≤ 4 (on a 1–5 scale, 5 better) after supratentorial brain tumor resections in adults with cardiovascular disease. 202 adults were randomized to intraoperative hemodynamic management guided by either CO or MAP. In patients assigned to CO guidance, clinicians targeted CO > 4 L/min and > 90% of baseline values using a combination of fluids and vasoactive agents. In patients assigned to MAP guidance, clinicians targeted MAP within ± 20% of baseline and ≥ 65 mmHg. Patients randomized to CO guidance were given more crystalloid and vasoactive support, resulting in significantly higher intraoperative CO and MAP. The proportion of patients with unfavorable 90-day Glasgow Outcome Scores (≤ 4) was non-significantly lower in the CO group (34% vs. 45%, P = 0.112). However, CO-guided management significantly reduced the incidence of postoperative cerebral edema (3% vs. 11%), reduced new neurological events (27% vs. 44%), and shortened hospitalization (median 8 vs. 9 days). While encouraging, findings from our small should be considered exploratory and warrant confirmation in adequately powered trials.