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Perioperative blood pressure control of hypertensive ICH patients

Perioperative blood pressure control of hypertensive ICH patients. 彰基神經外科 周啟文. APH has an early onset, being observed within 2 hours after surgery in most case. Occasionally, APH may persist for 24~48 hours . Complications of APH ： Hemorrhagic stroke 、 cerebral ischemia 、 encephalopathy 。

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Perioperative blood pressure control of hypertensive ICH patients

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  1. Perioperative blood pressure control of hypertensive ICH patients 彰基神經外科 周啟文

  2. APH has an early onset, being observed within 2 hours after surgery in most case. Occasionally, APH may persist for 24~48 hours. Complications of APH： Hemorrhagic stroke、cerebral ischemia、encephalopathy。 myocardial ischemia、myocardial infarction、cardiac arrhythmia、congestive heart failure。 Bleeding at the surgical site Acute Postoperative Hypertension：A review of therapeutic option Am J Health-Syst Pharm, 2004, Vol 61, 1661~1675

  3. Frequency of APH by Surgical Procedure Am J Health-Syst Pharm, 2004, Vol 61, 1661~1675

  4. Intracerebral hemorrhage is more than twice as common as subarachnoid hemorrhage(SAH) and is much more likely to result in death or major disability than cerebral infarction or SAH. Advancing age and hypertension are the most important risk factor for ICH. Guideline for the management of spontaneous intracranial hemorrhage Stroke, 1999, 30：905~915

  5. Cerebral amyloid angiopathy for elder Vascular malformations Ruptured aneurysm Coagulation disorders Use of anticoagulant and thrombolytic agent hemorrhage into a cerebral infarction Bleeding into brain tumor Drug abuse Cause of intracranial hemorrhage Stroke, 1999, 30：905~915

  6. Airway and oxygenation Blood pressure management Management of increased ICP Fluid management Prevention of seizure Management of Body temperature Treatment of Acute ICH Stroke, 1999, 30：905~915

  7. In general, recommendations for treatment of elevated blood pressure in patients with ICH are more aggressive than those for patients with ischemic stroke. Lowering blood pressure is to decrease the risk of ongoing bleeding from ruptured small arteries and arterioles. Conversely, overaggressive treatment of blood pressure may decrease cerebral perfusion pressure and theoretically worsen brain injury, particularly in the setting of increased intracranial pressure. Blood Pressure Management Stroke, 1999, 30：905~915

  8. Mean Blood Pressure＜130 mmHg (MBP＞110 mmHg should be avoid in the immediate postoperative period) Cranial Perfusion Pressure＞70 mmHg Intracranial Pressure＜20 mmHg Goal of Acute ICH Stroke, 1999, 30：905~915

  9. 彰基經驗 Blood pressure control and postoperative recurrence of hypertensive brain hemorrhage Hypertensive ICH (basal ganglion,subcortical) 2003 -2005 35 patient with postoperative aggressive control BP (MBP< 110, DBP<90) starting from OR to ICU 2002-2004 33 patient without active control BP > 2 episodes (MBP>110)

  10. 35 33 3

  11. Rupture of a cerebral aneurysm ＞50% Delayed vasospasm 1/3 Symptomatic ischemia ＞20% Permanent deficits or death Therapeutic Approach to Vasospasm in Subarachnoid Hemorrhage Current Opinion in Critical Care, 2002, 8：128~133

  12. Treatment of Vasospasm Stroke, 1999, 30：905~915

  13. Ideal Therapeutic Agents to Treat Perioperative Hypertension 1. Rapid onset of action 2. IV administration 3. Titratable 4. Vasodilator 5. Short half life Am J Health-Syst Pharm, 2004, Vol 61, 1661~1675

  14. Anti-Hyperetensive Drugs • Nitrates: • Nitroglycerin; Sodium Nitroprusside • Beta-Adrenergic Blockers: • Labetalol; Esmolol • Calcium Channel Blockers: • Diltiazem; Nifedipine; Nicardipine Am J Health-Syst Pharm, 2004, Vol 61, 1661~1675

  15. 基本資料 • 一般名 : Nicardipine hydrochloride • 結構式 :

  16. Mechanism of Perdipine ◆ Interfere Ca2+ Influx ◆ Vasodilation ◆ Avoid Intracellular Ca2+ Accumulation ◆ Cellular Protection

  17. Perdipine Injection的特性 ◆迅速發揮降壓效果，維持穩定血壓 ◆ 不會過度降低血壓，易調節用量 ◆ 增加腦，心臟，腎臟等重要臟器的血流量 ◆ 有利尿作用，可維持麻醉時的尿量 ◆ 除了靜脈滴注外，還可作直接靜脈注射

  18. Control Blood Pressure of Acute Cerebral Hemorrhage 22 patients with acute cerebral hemorrhage 24 Hour：1.140.45(range：0.61~1.69) μg/kg/min 72 Hour：0.60 0.45(range：0.24~1.06) μg/kg/min Can J Anesth, 2000, 47(12) ：1196~1201

  19. CT Finding Velocity of middle cerebral artery did not change Can J Anesth, 2000, 47(12) ：1196~1201

  20. Nicardipine as a Treatment for Cerebral Vasospasm 38 vessels in 18 patients with cerebral vasospasm, and treated with intra-arterial nicardipine 0.1mg/ml, 5mg per vessel AJNR Am J Neuroradiol, 2004, 25：819~826

  21. Perdipine Injection 適應症 適用於當口服治療不可行或不合適時， 對高血壓的短期處置

  22. Perdipine Injection用法、用量 （一）

  23. Perdipine Injection用法、用量 （二）

  24. Perdipine Injection Contraindications 1.Patients with known hypersensitivity to the drug. 2. Patients with suspected incomplete hemostasis following intracranial hemorrhage. 3. Patients with elevated intracranial pressure at the acute stage of cerebral stroke.

  25. Perdipine Injection Adverse Effects 總投藥病例634例 總投藥次數706次 無副作用 95.2% (山之內製藥統計)

  26. 血壓，心搏數的變化  維持穩定血壓,不會過度降低血壓

  27. 投藥前收縮壓別效果  血壓愈高降壓效果愈顯著 (%) 0 20 40 60 80 100 ~159 mmHg 71.0 160~179 mmHg 80.8 180 mmHg ~ 87.3 顯著效果 有效

  28. Nicardipine Increased Cerebral Blood flow  可增加腦血流量

  29. Effects of Nicardipine in Coronary Artery Disease  有意義的增加CO&CBF

  30. Perdipine Injection 之詳細用量 高血壓之控制 IV Bolus：迅速將血壓降下 建議劑量：10~30 g/kg 常用劑量：1.5~2.5 mL (slow push)，約可使 BP 降低 25~30%，可再以 iv infusion 投 藥持續控制血壓 手術時低壓控制 IV Infusion：常用起始劑量：5~10g/kg/min，待血壓控制於 55~65mmHg 時，再 降低劑量至 1g/kg/min 預防心或腦部之缺血、痙攣 IV Infusion：通常使用0.5~1.5 g/kg/min 使用於血管痙攣 IV Infusion：先投予 2~10 mg/hr，再依照血壓監測結果調整劑量 根據PDR, 2000：針對降血壓而給與的劑量為，起始劑量 5mg/mL，每 15min可增加 2.5mg/mL （若須快速降血壓，則每 5min 可增加劑量 2.5mg/mL），最大劑量可達到 15mg/mL。

  31. THANKS

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