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Hemodilution, Hypervolemic, Hypertension Therapy for Vasospasm patient Intern 陳凱峰.

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Presentation on theme: "Hemodilution, Hypervolemic, Hypertension Therapy for Vasospasm patient Intern 陳凱峰."— Presentation transcript:

1 Hemodilution, Hypervolemic, Hypertension Therapy for Vasospasm patient Intern 陳凱峰

2 Outline Vasospasm in SAH Rational of HHH therapy Pulmonary edema

3 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

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

5 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

6 Pharmacology Calcium channel blocker Mannitol Magnesium Antifibrinolytic Corticosteroid

7 HHH therapy First in 1976 For Reduced blood volume, plasma volume, erythrocyte mass 1. CVP ( hypervolemic) 2. Hct ( Hemodilution) 3. BP ( Hypertension)

8 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

9 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

10 Hypertension 30~40% more than baseline SBP Ischemic Symptom resolve  regional CBF in ischaemic brain areas Vasopressor  delayed global brain edema Phenylephrine, Dopamine preferred Best Practice & Research Clinical Anaesthesiology Vol. 18, No. 4, pp. 595–630, 2004

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

12 How Hypervolemic? Prophylactic post-op fluid therapy

13 Norway study Normovolemic GrA(16): 1000ml D5W ml N/S Until POD12 Keep I/O balance Hypervolemic GrB(16): 2000ml D5W ml N/S ~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

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15 Follow up with TCD and SPECT Neurosurgery, Vol. 49, No. 3, September 2001

16 Normal life independent Conscious Neurosurgery, Vol. 49, No. 3, September 2001

17 Complication

18 CPMC, NY June 1991 and October 1994 Aneurysmal SAH 2000;31; Stroke

19 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; Stroke

20 CBF 2000;31; Stroke

21 Complication NVHV Cerebral edema7 (17%)6 (15%) CHF01 (3%) Hyponatremia (<135) 2(5%)

22 Universal protocol? No double blind randomized clinical trial with exact dosage of fluid Collect three trials CPMC, Presbyterian Medical Center, New York quasi-randomised Cochrane Database Syst Rev Oct 18;(4):CD000483

23 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 Oct 18;(4):CD000483

24 How to reduce pulmonary edema rate? Reduction of Pulmonary Edema After SAH With a Pulmonary Artery Catheter-Guided Hemodynamic Management

25 How to reduce pulmonary edema rate? Sample: 453 spontaneous SAH Group I: 174 (July 1998 – Jan 2000 ) Group II: 279 ( Feb Jun 2002) identical Average age, Co-morbidity, hemorrhage severity, incidence of vasospasm Neurocritical Care August 2005, Volume 3, Issue 1, pps

26 Method – PA catheter guide Group I: 174 (July 1998 – Jan 2000 ) Hypervolemia : CVP > 8mmHg Hypertension: MAP: mmHg Group II: 279 ( Feb Jun 2002) normovolemia :wedge pressure: 10–14 mmHg Cardiac index: >4.5 L/minute/m2 Moderated HTN: mean pressure: >100 mmHg Neurocritical Care August 2005, Volume 3, Issue 1, pps

27 Group IGroup IIP value Pulmonary edema 14%6%<0.03 Sepsis rate14%6%<0.03 Mortality34%29%<0.04 Complication Neurocritical Care August 2005, Volume 3, Issue 1, pps

28 Summary 3 H therapy No randomize trial proved Monitor directed therapy is important

29 Thanks !


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