Neurocritical Care

, Volume 14, Issue 1, pp 24–36

Current Practices of Triple-H Prophylaxis and Therapy in Patients with Subarachnoid Hemorrhage

  • Rachel Meyer
  • Steven Deem
  • N. David Yanez
  • Michael Souter
  • Arthur Lam
  • Miriam M. Treggiari
Original Article



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.


Subarachnoid hemorrhage Cerebral vasospasm Triple-H therapy Delayed ischemic neurologic deficit Human Induced hypertension Volume expansion 


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Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Rachel Meyer
    • 1
    • 2
  • Steven Deem
    • 2
  • N. David Yanez
    • 3
  • Michael Souter
    • 2
    • 4
  • Arthur Lam
    • 2
    • 4
  • Miriam M. Treggiari
    • 2
    • 4
  1. 1.Mount Sinai School of MedicineNew YorkUSA
  2. 2.Department of Anesthesiology and Pain Medicine, Harborview Medical CenterUniversity of Washington School of MedicineSeattleUSA
  3. 3.Department of BiostatisticsUniversity of Washington School of Public Health and Community MedicineSeattleUSA
  4. 4.Department of Neurosurgical SurgeryUniversity of Washington School of MedicineSeattleUSA

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