Top Banner
Hemodilution, Hypervolemic, Hypertension Therapy for Vasospasm patient Intern 陳凱峰
29

Hemodilution, Hypervolemic, Hypertension Therapy for ...

Jul 15, 2015

Download

Documents

yashika54
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: Hemodilution, Hypervolemic, Hypertension Therapy for ...

Hemodilution, Hypervolemic, Hypertension Therapy for

Vasospasm patient

Intern 陳凱峰

Page 2: Hemodilution, Hypervolemic, Hypertension Therapy for ...

Outline

Vasospasm in SAH

Rational of HHH therapy

Pulmonary edema

Page 3: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 4: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 5: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 6: Hemodilution, Hypervolemic, Hypertension Therapy for ...

Pharmacology

Calcium channel blocker

Mannitol

Magnesium

Antifibrinolytic

Corticosteroid

Page 7: Hemodilution, Hypervolemic, Hypertension Therapy for ...

HHH therapy

First in 1976

For Reduced blood volume, plasma volume, erythrocyte mass

1. CVP ( hypervolemic)

2. Hct ( Hemodilution)

3. BP ( Hypertension)

Page 8: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 9: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 10: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 11: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 12: Hemodilution, Hypervolemic, Hypertension Therapy for ...

How Hypervolemic?

Prophylactic post-op fluid therapy

Page 13: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 14: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 15: Hemodilution, Hypervolemic, Hypertension Therapy for ...

Follow up with TCD and SPECT

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

Page 16: Hemodilution, Hypervolemic, Hypertension Therapy for ...

Normal life

independent

Conscious

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

Page 17: Hemodilution, Hypervolemic, Hypertension Therapy for ...

Complication

Page 18: Hemodilution, Hypervolemic, Hypertension Therapy for ...

CPMC, NY

•June 1991 and October 1994

•Aneurysmal SAH

2000;31;383-391 Stroke

Page 19: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 20: Hemodilution, Hypervolemic, Hypertension Therapy for ...

CBF

2000;31;383-391 Stroke

Page 21: Hemodilution, Hypervolemic, Hypertension Therapy for ...

Complication

NV HV

Cerebral edema 7 (17%) 6 (15%)

CHF 0 1 (3%)

Hyponatremia(<135)

2(5%) 2(5%)

Page 22: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 23: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 24: Hemodilution, Hypervolemic, Hypertension Therapy for ...

How to reduce pulmonary edema rate?

Reduction of Pulmonary Edema After SAH With a Pulmonary Artery Catheter-Guided Hemodynamic

Management

Page 25: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 26: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 27: Hemodilution, Hypervolemic, Hypertension Therapy for ...

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

Page 28: Hemodilution, Hypervolemic, Hypertension Therapy for ...

Summary

3 H therapy

No randomize trial proved

Monitor directed therapy is important

Page 29: Hemodilution, Hypervolemic, Hypertension Therapy for ...

Thanks !