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Hemodilution, Hypervolemic, Hypertension Therapy for Vasospasm patient

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

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Hemodilution, Hypervolemic, Hypertension Therapy for Vasospasm patient

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  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 NeuroscienceVolume 1, Issue 2 , April 1994, Pages 78-92

  12. How Hypervolemic? Prophylactic post-op fluid therapy

  13. 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

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

  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;383-391 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;383-391 Stroke

  20. CBF 2000;31;383-391 Stroke

  21. Complication

  22. 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

  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. 2004 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 2002 - Jun 2002) • identical Average age , Co-morbidity, hemorrhage severity, incidence of vasospasm Neurocritical CareAugust 2005, Volume 3, Issue 1, pps. 011-015

  26. 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

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

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

  29. Thanks !

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