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 Vasospasm
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

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
CMRO2 = CBF x OEF x SaO2
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. Prophylactic post-op fluid therapy
How Hypervolemic?
Prophylactic post-op fluid therapy

13. Norway study Normovolemic GrA(16): Hypervolemic GrB(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
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
norway
Mannitol
Nimodipine
TCD for vasospasm: flow MCA/ICA>3 >6 TCD vasospasm
GCS
Albumin, Dextran, Glycerol
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
BY GCS withini 1 year
5 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
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: ml 5% alb q2h
2000;31; Stroke

20. CBF
2000;31; Stroke

21. Complication NV HV Cerebral edema 7 (17%) 6 (15%) CHF 1 (3%)
1 (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 1999
2 quasi-randomised P
Cochrane Database Syst Rev Oct 18;(4):CD000483

23. Others even more complication
Only the Philadelphia trial ->reduce the frequency of preoperative secondary ischemia (1984)
Others even more complication
insufficient data on the effect of volume expansion
Thirty 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).
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
Difficult to monitor

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. Complication Group I Group II P value Pulmonary edema 14% 6% <0.03
Sepsis rate
Mortality
34%
29%
<0.04
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 !