Current Practices of Triple-H Prophylaxis and Therapy in Patients with Subarachnoid Hemorrhage
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
Medical management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) includes hypertensive, hypervolemic, and hemodilution (“triple-H”) therapy. However, there is little information regarding the indications and guidance used to initiate and adjust triple-H therapy.
A 43-item questionnaire was e-mailed to 375 members of the Neurocritical Care Society. Questions were designed to investigate the diagnostic approach to cerebral vasospasm and prophylactic and therapeutic administration of triple-H therapy.
Completed surveys were received from 167 respondents (45% response proportion). Eighty-six percent of respondents worked in hospitals with neurointensive care units (NICUs). SAH patients in hospitals with a NICU had longer ICU stay (P = 0.037) and had indwelling central venous catheters for longer (P < 0.01). Centers without dedicated NICUs were more likely to induce prophylactic hypervolemia (P < 0.01). Twenty seven percent of respondents (n = 45) reported using prophylactic hypervolemia in patients with SAH, while 100% reported inducing hypervolemia for severe or symptomatic vasospasm. Twelve percent (n = 20) of respondents reported inducing prophylactic hypertension, while all reported inducing hypertension with severe or symptomatic vasospasm. Half of respondents relied on the mean arterial pressure and half on systolic blood pressure as the clinical parameter for blood pressure titration. The most widely used agents to induce hypertension were phenylephrine (48%) and norepinephrine (39%). There was little variation in the use of hemodilution therapy comparing patients with or without evidence of vasospasm.
There are substantial differences in the administration of prophylactic triple-H, but there was high agreement on indication for therapeutic use. There was wide variability in the extent of ICU monitoring, diagnostic approach, physiologic parameters and values used as target of therapy. NICU availability was associated with more intensive monitoring. Lack of evidence and guidelines for triple-H therapy might largely explain these findings.
- de Rooij NK, Linn FH, van der Plas JA, et al. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry. 2007;78:1365–72. CrossRef
- King JT Jr. Epidemiology of aneurysmal subarachnoid hemorrhage. Neuroimaging Clin N Am. 1997;7:659–68.
- Biller J, Godersky JC, Adams HP Jr. Management of aneurysmal subarachnoid hemorrhage. Stroke. 1988;19:1300–5.
- Treggiari-Venzi MM, Suter PM, Romand JA. Review of medical prevention of vasospasm after aneurysmal subarachnoid hemorrhage: a problem of neurointensive care. Neurosurgery. 2001;48:249–61 (discussion 61–2). CrossRef
- Lennihan L, Mayer SA, Fink ME, et al. Effect of hypervolemic therapy on cerebral blood flow after subarachnoid hemorrhage: a randomized controlled trial. Stroke. 2000;31:383–91.
- Egge A, Waterloo K, Sjoholm H, et al. Prophylactic hyperdynamic postoperative fluid therapy after aneurysmal subarachnoid hemorrhage: a clinical, prospective, randomized, controlled study. Neurosurgery. 2001;49:593–605 (discussion 605-6). CrossRef
- Solenski NJ, Haley EC Jr, Kassell NF, et al. Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study. Crit Care Med. 1995;23:1007–17. CrossRef
- Gruber A, Reinprecht A, Gorzer H, et al. Pulmonary function and radiographic abnormalities related to neurological outcome after aneurysmal subarachnoid hemorrhage. J Neurosurg. 1998;88:28–37. CrossRef
- Wartenberg KE, Schmidt JM, Claassen J, et al. Impact of medical complications on outcome after subarachnoid hemorrhage. Crit Care Med. 2006;34:617–23. quiz 24. CrossRef
- Muench E, Horn P, Bauhuf C, et al. Effects of hypervolemia and hypertension on regional cerebral blood flow, intracranial pressure, and brain tissue oxygenation after subarachnoid hemorrhage. Crit Care Med. 2007;35:1844–51. CrossRef
- Stevens RD, Naval NS, Mirski MA, et al. Intensive care of aneurysmal subarachnoid hemorrhage: an international survey. Intensive Care Med. 2009;35:1556–66. CrossRef
- Bederson JB, Connolly ES Jr, Batjer HH, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009;40:994–1025. CrossRef
- Bershad EM, Feen ES, Hernandez OH, et al. Impact of a specialized neurointensive care team on outcomes of critically ill acute ischemic stroke patients. Neurocrit Care. 2008;9:287–92. CrossRef
- Current Practices of Triple-H Prophylaxis and Therapy in Patients with Subarachnoid Hemorrhage
Volume 14, Issue 1 , pp 24-36
- Cover Date
- Print ISSN
- Online ISSN
- Humana Press Inc
- Additional Links
- Subarachnoid hemorrhage
- Cerebral vasospasm
- Triple-H therapy
- Delayed ischemic neurologic deficit
- Induced hypertension
- Volume expansion
- Industry Sectors
- Author Affiliations
- 1. Mount Sinai School of Medicine, New York, NY, USA
- 2. Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington School of Medicine, 325 Ninth Avenue, Box 359724, Seattle, WA, 98104, USA
- 3. Department of Biostatistics, University of Washington School of Public Health and Community Medicine, Seattle, WA, USA
- 4. Department of Neurosurgical Surgery, University of Washington School of Medicine, Seattle, WA, USA