hemodilution, hypervolemic, hypertension therapy for

Hemodilution, Hypervolemic, Hypertension Therapy for

Vasospasm patient

Intern 陳凱峰

Outline

Vasospasm in SAH

Rational of HHH therapy

Pulmonary edema

Vasospasm in SAH

SAH hydrocephalus, meningeal irritation, fluid and e

disturbances, cerebral vasospasm

Vasospasm True vasospasm after clipping / coiling Limitation of CBF More due to remodeling of blood vessel Peak: 7~10 days after bleeding

Best Practice & Research Clinical Anaesthesiology Vol. 18, No. 4, pp. 595–630, 2004

Neuro-protective

Hyperoxygenation

Hypothermia

Avoid hyperthermia

Avoid hyperglycemia

Triple H ( hypertension, hemodilution, hypervolemia) ↑CBF and prevent ischemia

Best Practice & Research Clinical Anaesthesiology

Vol. 18, No. 4, pp. 595–630, 2004

Pharmacology

Calcium channel blocker

Mannitol

Magnesium

Antifibrinolytic

Corticosteroid

HHH therapy

First in 1976

For Reduced blood volume, plasma volume, erythrocyte mass

1. CVP ( hypervolemic)

2. Hct ( Hemodilution)

3. BP ( Hypertension)

Hypervolemia

Hypovolemia ( cerebral salt-wasting)

Reduced delayed cerebral ischemia

IVF

Complicated with pulmonary edema, brain edema

Hard to monitor and target

Best Practice & Research Clinical Anaesthesiology

Vol. 18, No. 4, pp. 595–630, 2004

Hemodilution

↓Hct to 30%~35%

Cerebral oxygen transport and cerebral O2 metabolism

Crystalloid, plasma volume expander Dextran, albumin

Best Practice & Research Clinical Anaesthesiology

Vol. 18, No. 4, pp. 595–630, 2004

Hypertension

30~40% more than baseline SBPIschemic Symptom resolve↑ regional CBF in ischaemic brain areasVasopressor delayed global brain edemaPhenylephrine, Dopamine preferred

Best Practice & Research Clinical Anaesthesiology

Vol. 18, No. 4, pp. 595–630, 2004

Journal of Clinical Neuroscience Volume 1, Issue 2 , April 1994, Pages 78-92

How Hypervolemic?

Prophylactic post-op fluid therapy

Norway study

Normovolemic GrA(16): 1000ml D5W + 1000ml N/S Until POD12 Keep I/O balance

Hypervolemic GrB(16): 2000ml D5W + 2000 ml N/S + 1000~1500 ml colloids Colloid: 500 ml of 4% albumin solution and/or 500–

1000 ml of Rheomacrodex (Dextran 40) Until POD 12 CVP: 8~12 MAP: 20%> baseline with Dopamine 5–15 g/kg/min

Neurosurgery, Vol. 49, No. 3, September 2001

Neurosurgery, Vol. 49, No. 3, September 2001

Follow up with TCD and SPECT

Neurosurgery, Vol. 49, No. 3, September 2001

Normal life

independent

Conscious

Neurosurgery, Vol. 49, No. 3, September 2001

Complication

CPMC, NY

•June 1991 and October 1994

•Aneurysmal SAH

2000;31;383-391 Stroke

CPMC

•HV: PADP>14mmHg

CVP>8mmHg

•NV: PADP 7mmHg

CVP: 5 mmHg

•Fluid

HV & NV: D5W 80ml/h

0.9% saline 80ml/h

HV: 250ml 5% alb q2h 2000;31;383-391 Stroke

CBF

2000;31;383-391 Stroke

Complication

NV HV

Cerebral edema 7 (17%) 6 (15%)

CHF 0 1 (3%)

Hyponatremia(<135)

2(5%) 2(5%)

Universal protocol?

No double blind randomized clinical trial with exact dosage of fluid

Collect three trials CPMC, Presbyterian Medical Center, New

York 1999 2 quasi-randomised

Cochrane Database Syst Rev. 2004 Oct 18;(4):CD000483

Only the Philadelphia trial ->reduce the frequency of preoperative secondary ischemia (1984)

Others even more complication

insufficient data on the effect of volume expansion

Cochrane Database Syst Rev. 2004 Oct 18;(4):CD000483

How to reduce pulmonary edema rate?

Reduction of Pulmonary Edema After SAH With a Pulmonary Artery Catheter-Guided Hemodynamic

Management

How to reduce pulmonary edema rate?

Sample: 453 spontaneous SAH

Group I: 174 (July 1998 – Jan 2000 )

Group II: 279 ( Feb 2002 - Jun 2002)

identical Average age , Co-morbidity, hemorrhage severity, incidence of vasospasm

Neurocritical CareAugust 2005, Volume 3, Issue 1, pps. 011-015

Method – PA catheter guide

Group I: 174 (July 1998 – Jan 2000 ) Hypervolemia : CVP > 8mmHg Hypertension: MAP: 110-130 mmHg

Group II: 279 ( Feb 2002 - Jun 2002) normovolemia :wedge pressure: 10–14 mmHg Cardiac index: >4.5 L/minute/m2 Moderated HTN: mean pressure: >100 mmHg

Neurocritical CareAugust 2005, Volume 3, Issue 1, pps. 011-015

Group I Group II P value

Pulmonary edema

14% 6% <0.03

Sepsis rate 14% 6% <0.03

Mortality 34% 29% <0.04

Complication

Neurocritical CareAugust 2005, Volume 3, Issue 1, pps. 011-015

Summary

3 H therapy

No randomize trial proved

Monitor directed therapy is important

Thanks !