Upload
yashika54
View
1.935
Download
3
Embed Size (px)
Citation preview
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 !