Hemodilution, Hypervolemic, Hypertension Therapy for

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<ul><li><p>Hemodilution, Hypervolemic, Hypertension Therapy for Vasospasm patientIntern </p></li><li><p>OutlineVasospasm in SAH Rational of HHH therapyPulmonary edema</p></li><li><p>Vasospasm in SAHSAH hydrocephalus, meningeal irritation, fluid and e disturbances, cerebral vasospasmVasospasmTrue vasospasm after clipping / coilingLimitation of CBFMore due to remodeling of blood vesselPeak: 7~10 days after bleeding</p></li><li><p>Best Practice &amp; Research Clinical Anaesthesiology Vol. 18, No. 4, pp. 595630, 2004</p></li><li><p>Neuro-protectiveHyperoxygenationHypothermiaAvoid hyperthermiaAvoid hyperglycemiaTriple H ( hypertension, hemodilution, hypervolemia) CBF and prevent ischemia Best Practice &amp; Research Clinical AnaesthesiologyVol. 18, No. 4, pp. 595630, 2004</p></li><li><p>PharmacologyCalcium channel blockerMannitolMagnesiumAntifibrinolyticCorticosteroid </p></li><li><p>HHH therapyFirst in 1976For Reduced blood volume, plasma volume, erythrocyte mass1. CVP ( hypervolemic)2. Hct ( Hemodilution)3. BP ( Hypertension)</p></li><li><p>HypervolemiaHypovolemia ( cerebral salt-wasting)Reduced delayed cerebral ischemiaIVFComplicated with pulmonary edema, brain edemaHard to monitor and target</p><p>Best Practice &amp; Research Clinical AnaesthesiologyVol. 18, No. 4, pp. 595630, 2004</p></li><li><p>HemodilutionHct to 30%~35%Cerebral oxygen transport and cerebral O2 metabolismCrystalloid, plasma volume expander Dextran, albuminBest Practice &amp; Research Clinical AnaesthesiologyVol. 18, No. 4, pp. 595630, 2004</p></li><li><p>Hypertension30~40% more than baseline SBPIschemic Symptom resolve regional CBF in ischaemic brain areasVasopressor delayed global brain edemaPhenylephrine, Dopamine preferred</p><p>Best Practice &amp; Research Clinical AnaesthesiologyVol. 18, No. 4, pp. 595630, 2004</p></li><li><p> Journal of Clinical Neuroscience Volume 1, Issue 2 , April 1994, Pages 78-92</p></li><li><p>How Hypervolemic?Prophylactic post-op fluid therapy</p></li><li><p>Norway studyNormovolemic GrA(16): 1000ml D5W + 1000ml N/SUntil POD12Keep I/O balanceHypervolemic GrB(16): 2000ml D5W + 2000 ml N/S + 1000~1500 ml colloidsColloid: 500 ml of 4% albumin solution and/or 5001000 ml of Rheomacrodex (Dextran 40)Until POD 12CVP: 8~12MAP: 20%&gt; baseline with Dopamine 515 g/kg/min</p><p>Neurosurgery, Vol. 49, No. 3, September 2001</p></li><li><p>Neurosurgery, Vol. 49, No. 3, September 2001</p></li><li><p>Follow up with TCD and SPECTNeurosurgery, Vol. 49, No. 3, September 2001</p></li><li><p>Normal lifeindependentConsciousNeurosurgery, Vol. 49, No. 3, September 2001</p></li><li><p>Complication</p></li><li><p>CPMC, NYJune 1991 and October 1994Aneurysmal SAH</p><p>2000;31;383-391 Stroke</p></li><li><p>CPMC</p><p>HV: PADP&gt;14mmHgCVP&gt;8mmHgNV: PADP 7mmHgCVP: 5 mmHgFluid HV &amp; NV: D5W 80ml/h 0.9% saline 80ml/hHV: 250ml 5% alb q2h2000;31;383-391 Stroke</p></li><li><p>CBF2000;31;383-391 Stroke</p></li><li><p>Complication</p><p>NVHVCerebral edema7 (17%)6 (15%)CHF01 (3%)Hyponatremia(</p></li><li><p>Universal protocol?No double blind randomized clinical trial with exact dosage of fluidCollect three trialsCPMC, Presbyterian Medical Center, New York 19992 quasi-randomised</p><p>Cochrane Database Syst Rev. 2004 Oct 18;(4):CD000483 </p></li><li><p>Only the Philadelphia trial -&gt;reduce the frequency of preoperative secondary ischemia (1984)Others even more complicationinsufficient data on the effect of volume expansion</p><p>Cochrane Database Syst Rev. 2004 Oct 18;(4):CD000483 </p></li><li><p>How to reduce pulmonary edema rate?Reduction of Pulmonary Edema After SAH With a Pulmonary Artery Catheter-Guided Hemodynamic Management</p></li><li><p>How to reduce pulmonary edema rate?Sample: 453 spontaneous SAHGroup I: 174 (July 1998 Jan 2000 )Group II: 279 ( Feb 2002 - Jun 2002)identical Average age , Co-morbidity, hemorrhage severity, incidence of vasospasm</p><p>Neurocritical Care August2005,Volume 3,Issue 1,pps. 011-015</p></li><li><p>Method PA catheter guideGroup I: 174 (July 1998 Jan 2000 )Hypervolemia : CVP &gt; 8mmHgHypertension: MAP: 110-130 mmHgGroup II: 279 ( Feb 2002 - Jun 2002)normovolemia :wedge pressure: 1014 mmHgCardiac index: &gt;4.5 L/minute/m2Moderated HTN: mean pressure: &gt;100 mmHgNeurocritical Care August2005,Volume 3,Issue 1,pps. 011-015</p></li><li><p>ComplicationNeurocritical Care August2005,Volume 3,Issue 1,pps. 011-015</p><p>Group IGroup IIP valuePulmonary edema14%6%</p></li><li><p>Summary3 H therapyNo randomize trial provedMonitor directed therapy is important</p></li><li><p>Thanks !</p><p>CMRO2 = CBF x OEF x SaO2 32 patients received continuous intravenous nimodipine infusions (0.2 mg/ml, 10 ml/h) for the entire study period (Days 1 to 12), followed by oral administration (360 mg/d) for 10 to 14 days norwayMannitolNimodipineTCD for vasospasm: flow MCA/ICA&gt;3 &gt;6 TCD vasospasmGCSAlbumin, Dextran, Glycerol BY GCS withini 1 year5 Good Recovery Resumption of normal life despite minor deficits 4 Moderate Disability Disabled but independent. Can work in sheltered setting 3 Severe Disability Conscious but disabled. Dependent for daily support 2 Persistent vegetative Minimal responsiveness 1 Death Non survival PThirty hypertensive patients with subarachnoid hemorrhage were divided randomly into two groups. The treated group was begun on preliminary volume expansion, and control of hypertension was carried out using vasodilators and centrally acting drugs. The control group was treated in the classical manner for hypertension, with a diuretic as the foundation for therapy. The incidence of clinical vasospasm was compared to that of angiographic spasm. The incidence of preoperative vasospasm in the treated group was 20%, as compared to 60% in the untreated group (P less than 0.01). Of the treated group, 87% survived to operation, whereas only 53% of the control group survived to operation (P less than 0.01). Difficult to monitor</p></li></ul>

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