Show pageBacklinksCite current pageExport to PDFBack to top This page is read only. You can view the source, but not change it. Ask your administrator if you think this is wrong. ====== Triple H therapy for cerebral vasospasm ====== __//[[Triple H therapy]] controversial//__ ---- It is often utilized to prevent and treat [[cerebral vasospasm]] after [[aneurysmal subarachnoid hemorrhage]] (SAH). Although this paradigm has gained widespread acceptance since 1985, the efficacy of triple-H therapy and its precise role in the management of the acute phase of SAH remains uncertain. In addition, triple-H therapy may carry significant medical morbidity, including [[pulmonary edema]], [[myocardial infarction]], [[hyponatremia]], renal medullary washout, indwelling catheter-related complications, cerebral hemorrhage, and cerebral edema ((Lee KH, Lukovits T, Friedman JA. "Triple-H" therapy for cerebral vasospasm following subarachnoid hemorrhage. Neurocrit Care. 2006;4(1):68-76. Review. PubMed PMID: 16498198. )). This practice is based on low level evidence. ---- see [[Induced hypertension for vasospasm]]. ---- Many older [[treatment]] schemes for [[CVS]] included so-called “triple- H” therapy (for [[Hypervolemia]], [[Hypertension]], and [[Hemodilution]]) ((Origitano TC, Wascher TM, Reichman OH, et al. Sustained Increased Cerebral Blood Flow with Prophylactic Hypertensive Hypervolemic Hemodilution ("Triple-H" Therapy) After Subarachnoid Hemorrhage. Neurosurgery. 1990; 27:729–740)). This has given way to “[[hemodynamic augmentation]]” consisting of maintenance of [[euvolemia]] and induced [[arterial hypertension]] ((Dankbaar JW, Slooter AJ, Rinkel GJ, et al. Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review. Crit Care. 2010; 14. DOI: 10.1186/cc8886)). While potentially confusing, this has now sometimes been referred to as Triple-H therapy ((Connolly ES,Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurys- mal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012; 43:1711–1737)). Inducing [[HTN]] may be risky with an unclipped [[ruptured aneurysm]]. Once the aneurysm is treated, initiating therapy before CVS is apparent may minimize morbidity from CVS ((Solomon RA, Fink ME, Lennihan L. Prophylactic Volume Expansion Therapy for the Prevention of Delayed Cerebral Ischemia After Early Aneurysm Surgery. Arch Neurol. 1988; 45:325–332)) ((Solomon RA, Fink ME, Lennihan L. Early Aneurysm Surgery and Prophylactic Hypervolemic Hypertensive Therapy for the Treatment of Aneurysmal Subarachnoid Hemorrhage. Neurosurgery. 1988; 23:699–704)). Use fluids to maintain [[euvolemia]]. Administer pressors to increase [[SBP]] in 15% increments until neurologically improved or SBP of 220 mm Hg is reached. Agents include: ● [[dopamine]] ○ start at 2.5 mcg/kg/min (renal dose) ○ titrate up to 15–20 mcg/kg/min ● [[levophed]] ○ start at 1–2 mcg/min ○ titrate every 2–5 minutes: double the rate up to 64 mcg/min, then increase by 10 mcg/min ● [[neosynephrine]] ([[phenylephrine]]): does not exacerbate [[tachycardia]] ○ start at 5 mcg/min ○ titrate every 2–5 minutes: double the rate up to 64 mcg/min, then increase by 10 mcg/min up to a max of 10 mcg/kg ● [[dobutamine]]: positive inotrope ○ start at 5 mcg/kg/min ○ increase dose by 2.5 mcg/kg/min up to a maximum of 20 mcg/kg/min Complications of hemodynamic augmentation: ● intracranial complications ((Shimoda M, Oda S, Tsugane R, et al. Intracranial Complications of Hypervolemic Therapy in Patients with a Delayed Ischemic Deficit Attributed to Vasospasm. J Neurosurg. 1993; 78: 423–429)) ○ may exacerbate cerebral edema and increase ICP ○ may produce hemorrhagic infarction in an area of previous ischemia ● extracranial complications ○ [[pulmonary edema]] in 17% ○ 3 rebleeds (1 fatal) ○ MI in 2% ○ complications of PA catheter: ((Rosenwasser RH, Jallo JI, Getch CC, et al. Complications of Swan-Ganz Catheterization for Hemodynamic Monitoring in Patients with Subarachnoid Hemorrhage. Neurosurgery. 1995; 37:872–876)) – catheter related sepsis: 13% – subclavian vein thrombosis: 1.3% – pneumothorax: 1% – hemothorax: may be promoted by coagulopathy from dextran ((Shimoda M, Oda S, Tsugane R, et al. Intracranial Complications of Hypervolemic Therapy in Patients with a Delayed Ischemic Deficit Attributed to Vasospasm. J Neurosurg. 1993; 78: 423–429)). ===== Case series ===== In a study of Engquist et al. from [[Uppsala]], [[CBF]] was assessed by bedside [[xenon CT]] at days 0-3, 4-7, and 8-12, and the cerebral metabolic state by [[cerebral microdialysis]] (CMD), analyzing [[glucose]], [[lactate]], [[pyruvate]], and [[glutamate]] hourly. At clinical suspicion of [[DCI]], [[HHH]] therapy was instituted for 5 days. [[Cerebral blood flow measurement]]s and CMD data at baseline and during HHH therapy were required for study inclusion. Non-[[DCI]] patients with measurements in corresponding time windows were included as a reference group. In DCI patients receiving HHH therapy (n = 12), global cortical CBF increased from 30.4 ml/100 g/min (IQR 25.1-33.8 ml/100 g/min) to 38.4 ml/100 g/min (IQR 34.2-46.1 ml/100 g/min; p = 0.006). The energy metabolic CMD parameters stayed statistically unchanged with a [[Lactate to Pyruvate Ratio]] of 26.9 (IQR 22.9-48.5) at baseline and 31.6 (IQR 22.4-35.7) during HHH. Categorized by energy metabolic patterns during HHH, no patient had severe [[ischemia]], 8 showed derangement corresponding to mitochondrial dysfunction, and 4 were normal. The reference group of non-DCI patients (n = 11) had higher CBF and lower L/P ratios at baseline with no change over time, and the metabolic pattern was normal in all these patients. Global and regional [[CBF]] improved and the cerebral energy metabolic [[CMD]] parameters stayed statistically unchanged during [[HHH]] therapy in [[DCI]] patients. None of the patients developed metabolic signs of severe [[ischemia]], but a disturbed energy metabolic pattern was a common occurrence, possibly explained by [[mitochondrial dysfunction]] despite improved [[microcirculation]] ((Engquist H, Lewén A, Hillered L, Ronne-Engström E, Nilsson P, Enblad P, Rostami E. CBF changes and cerebral energy metabolism during hypervolemia, hemodilution, and hypertension therapy in patients with poor-grade subarachnoid hemorrhage. J Neurosurg. 2020 Jan 10:1-10. doi: 10.3171/2019.11.JNS192759. [Epub ahead of print] PubMed PMID: 31923897. )). ---- An audit of the SAH patient charts was performed. A total of 508 fluid measurements were performed in 41 patients (6 with delayed cerebral ischaemia; DCI) during 14 days of observation. Underestimating for intravenous drugs was the most frequent error (80.6%; 112), resulting in a false positive fluid balance in 2.4% of estimations. In 38.6% of the negative fluid balance cases, the physicians did not order additional fluids for the next 24h. In spite of that, the fluid intake was significantly increased after DCI diagnosis. The mean and median intake values were 3.5 and 3.8l/24h respectively, although 40% of the fluid balances were negative. The positive to negative fluid balance ratio was decreasing in the course of the 14 day observation. This study revealed inconsistencies in the fluid orders as well as mistakes in the fluid monitoring, which illustrates the difficulties of fluid therapy and reinforces the need for strong evidence-based guidelines for hypervolemic therapy in SAH ((Szmuda T, Waszak PM, Rydz C, Springer J, Budynko L, Szydlo A, Sloniewski P, Dzierżanowski J. The challenges of hypervolemic therapy in patients after subarachnoid haemorrhage. Neurol Neurochir Pol. 2014;48(5):328-36. doi: 10.1016/j.pjnns.2014.09.001. Epub 2014 Oct 13. PubMed PMID: 25440011. )). ===== References ===== triple_h_therapy_for_cerebral_vasospasm.txt Last modified: 2024/06/07 02:57by 127.0.0.1