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Effect of Triple-H Prophylaxis on Global End-Diastolic Volume and Clinical Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage

Neurocritical Care volume 21, pages 462–469 (2014)Cite this article

Abstract

Background

Although prophylactic triple-H therapy has been used in a number of institutions globally to prevent delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH), limited evidence is available for the effectiveness of triple-H therapy on hemodynamic variables. Recent studies have suggested an association between low global end-diastolic volume index (GEDI), measured using a transpulmonary thermodilution method, and DCI onset. The current study aimed at assessing the effects of prophylactic triple-H therapy on GEDI.

Methods

This prospective multicenter study included aneurysmal SAH patients admitted to 9 hospitals in Japan. The decision to administer prophylactic triple-H therapy and the management protocols were left to the physician in charge (physician-directed therapy) of each participating institution. The primary endpoints were the changes in the hemodynamic variables as analyzed using a generalized linear mixed model.

Results

Of 178 patients, 62 (34.8 %) received prophylactic triple-H therapy and 116 (65.2 %) did not. DCI was observed in 35 patients (19.7 %), with no significant difference between the two groups [15 (24.2 %) vs. 20 (17.2 %), p = 0.27]. Although a greater amount of fluid (p < 0.001) and a higher mean arterial pressure (p = 0.005) were observed in the triple-H group, no significant difference was observed between the groups in GEDI (p = 0.81) or cardiac output (p = 0.62).

Conclusions

Physician-directed prophylactic triple-H administration was not associated with improved clinical outcomes or quantitative hemodynamic indicators for intravascular volume. Further, GEDI-directed intervention studies are warranted to better define management algorithms for SAH patients with the aim of preventing DCI.

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References

  1. 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.

    Article  PubMed  Google Scholar 

  2. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43:1711–37.

    Article  PubMed  Google Scholar 

  3. van den Berg R, Foumani M, Schroder RD, et al. Predictors of outcome in World Federation of Neurologic Surgeons grade V aneurysmal subarachnoid hemorrhage patients. Crit Care Med. 2011;39:2722–7.

    PubMed  Google Scholar 

  4. Frontera JA, Fernandez A, Schmidt JM, et al. Defining vasospasm after subarachnoid hemorrhage: what is the most clinically relevant definition? Stroke. 2009;40:1963–8.

    Article  PubMed  Google Scholar 

  5. Vergouwen MD, Vermeulen M, van Gijn J, et al. Definition of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage as an outcome event in clinical trials and observational studies: proposal of a multidisciplinary research group. Stroke. 2010;41:2391–5.

    Article  PubMed  Google Scholar 

  6. Hoff R, Rinkel G, Verweij B, Algra A, Kalkman C. Blood volume measurement to guide fluid therapy after aneurysmal subarachnoid hemorrhage: a prospective controlled study. Stroke. 2009;40:2575–7.

    Article  PubMed  Google Scholar 

  7. Kasuya H, Onda H, Yoneyama T, Sasaki T, Hori T. Bedside monitoring of circulating blood volume after subarachnoid hemorrhage. Stroke. 2003;34:956–60.

    Article  PubMed  Google Scholar 

  8. Meyer R, Deem S, David Yanez N, Souter M, Lam A, Treggiari MM. Current practices of triple-H prophylaxis and therapy in patients with subarachnoid hemorrhage. Neurocrit Care. 2010;14:24–36.

    Article  Google Scholar 

  9. Rinkel GJ, Feigin VL, Algra A, van Gijn J. Circulatory volume expansion therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2004:CD000483.

  10. Diringer MN, Bleck TP, Claude Hemphill J III, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15:211–40.

    Article  PubMed  Google Scholar 

  11. Treggiari MM, Walder B, Suter PM, Romand JA. Systematic review of the prevention of delayed ischemic neurological deficits with hypertension, hypervolemia, and hemodilution therapy following subarachnoid hemorrhage. J Neurosurg. 2003;98:978–84.

    Article  PubMed  Google Scholar 

  12. Egge A, Waterloo K, Sjoholm H, Solberg T, Ingebrigtsen T, Romner B. Prophylactic hyperdynamic postoperative fluid therapy after aneurysmal subarachnoid hemorrhage: a clinical, prospective, randomized, controlled study. Neurosurgery. 2001;49:593–605 discussion 605-596.

    CAS  PubMed  Google Scholar 

  13. 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.

    Article  CAS  PubMed  Google Scholar 

  14. Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013;41:1774–81.

    Article  PubMed  Google Scholar 

  15. Tagami T, Kuwamoto K, Watanabe A, et al. Optimal range of global end-diastolic volume for fluid management after aneurysmal subarachnoid hemorrhage: a multicenter prospective cohort study. Crit Care Med. 2014.

  16. Lazaridis C. Advanced hemodynamic monitoring: principles and practice in neurocritical care. Neurocrit Care. 2012;16:163–9.

    Article  PubMed  Google Scholar 

  17. Mutoh T, Kazumata K, Ajiki M, Ushikoshi S, Terasaka S. Goal-directed fluid management by bedside transpulmonary hemodynamic monitoring after subarachnoid hemorrhage. Stroke. 2007;38:3218–24.

    Article  PubMed  Google Scholar 

  18. Mutoh T, Kazumata K, Ishikawa T, Terasaka S. Performance of bedside transpulmonary thermodilution monitoring for goal-directed hemodynamic management after subarachnoid hemorrhage. Stroke. 2009;40:2368–74.

    Article  PubMed  Google Scholar 

  19. Segal E, Greenlee JD, Hata SJ, Perel A. Monitoring intravascular volumes to direct hypertensive, hypervolemic therapy in a patient with vasospasm. J Neurosurg Anesthesiol. 2004;16:296–8.

    Article  PubMed  Google Scholar 

  20. Michard F, Alaya S, Zarka V, Bahloul M, Richard C, Teboul JL. Global end-diastolic volume as an indicator of cardiac preload in patients with septic shock. Chest. 2003;124:1900–8.

    Article  PubMed  Google Scholar 

  21. Watanabe A, Tagami T, Yokobori S, et al. Global end-diastolic volume is associated with the occurrence of delayed cerebral ischemia and pulmonary edema after subarachnoid hemorrhage. Shock. 2012;38:480–5.

    Article  PubMed  Google Scholar 

  22. Yoneda H, Nakamura T, Shirao S, et al. Multicenter prospective cohort study on volume management after subarachnoid hemorrhage: hemodynamic changes according to severity of subarachnoid hemorrhage and cerebral vasospasm. Stroke. 2013;44:2155–61.

    Article  PubMed  Google Scholar 

  23. Jordan LC, Johnston SC, Wu YW, Sidney S, Fullerton HJ. The importance of cerebral aneurysms in childhood hemorrhagic stroke: a population-based study. Stroke. 2009;40:400–5.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Sakowitz OW, Raabe A, Vucak D, Kiening KL, Unterberg AW. Contemporary management of aneurysmal subarachnoid hemorrhage in Germany: results of a survey among 100 neurosurgical departments. Neurosurgery. 2006;58:137–45.

    Article  PubMed  Google Scholar 

  25. Stevens RD, Naval NS, Mirski MA, Citerio G, Andrews PJ. Intensive care of aneurysmal subarachnoid hemorrhage: an international survey. Intensive Care Med. 2009;35:1556–66.

    Article  PubMed  Google Scholar 

  26. Meyer R, Deem S, Yanez ND, Souter M, Lam A, Treggiari MM. Current practices of triple-H prophylaxis and therapy in patients with subarachnoid hemorrhage. Neurocrit Care. 2011;14:24–36.

    Article  PubMed  Google Scholar 

  27. Kurtz P, Helbok R, Ko SB, et al. Fluid responsiveness and brain tissue oxygen augmentation after subarachnoid hemorrhage. Neurocrit Care. 2013.

  28. Monnet X, Persichini R, Ktari M, Jozwiak M, Richard C, Teboul JL. Precision of the transpulmonary thermodilution measurements. Crit Care. 2011;15:R204.

    Article  PubMed Central  PubMed  Google Scholar 

  29. Tagami T, Kushimoto S, Tosa R, et al. The precision of PiCCO measurements in hypothermic post-cardiac arrest patients. Anaesthesia. 2012;67:236–43.

    Article  CAS  PubMed  Google Scholar 

  30. Sakka SG, Reuter DA, Perel A. The transpulmonary thermodilution technique. J Clin Monit Comput. 2012;26:347–53.

    Article  PubMed  Google Scholar 

  31. Badjatia N, Carpenter A, Fernandez L, et al. Relationship between C-reactive protein, systemic oxygen consumption, and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Stroke. 2011;42:2436–42.

    Article  CAS  PubMed  Google Scholar 

  32. Sen J, Belli A, Albon H, Morgan L, Petzold A, Kitchen N. Triple-H therapy in the management of aneurysmal subarachnoid haemorrhage. Lancet Neurol. 2003;2:614–20.

    Article  PubMed  Google Scholar 

  33. Rondeau N, Cinotti R, Rozec B, et al. Dobutamine-induced high cardiac index did not prevent vasospasm in subarachnoid hemorrhage patients: a randomized controlled pilot study. Neurocrit Care. 2012;17:183–90.

    Article  CAS  PubMed  Google Scholar 

  34. Velat GJ, Kimball MM, Mocco JD, Hoh BL. Vasospasm after aneurysmal subarachnoid hemorrhage: review of randomized controlled trials and meta-analyses in the literature. World Neurosurg. 2011;76:446–54.

    Article  PubMed  Google Scholar 

  35. Ibrahim GM, Macdonald RL. The effects of fluid balance and colloid administration on outcomes in patients with aneurysmal subarachnoid hemorrhage: a propensity score-matched analysis. Neurocrit Care. 2013;19:140–9.

    Article  CAS  PubMed  Google Scholar 

  36. Lu N, Jackson D, Luke S, Festic E, Hanel RA, Freeman WD. Intraventricular nicardipine for aneurysmal subarachnoid hemorrhage related vasospasm: assessment of 90 days outcome. Neurocrit Care. 2012;16:368–75.

    Article  CAS  PubMed  Google Scholar 

  37. Ortega-Gutierrez S, Thomas J, Reccius A, et al. Effectiveness and safety of nicardipine and labetalol infusion for blood pressure management in patients with intracerebral and subarachnoid hemorrhage. Neurocrit Care. 2013;18:13–9.

    Article  CAS  PubMed  Google Scholar 

  38. Goepfert MS, Richter HP, Eulenburg CZ, et al. Individually optimized hemodynamic therapy reduces complications and length of stay in the intensive care unit: a prospective, randomized controlled trial. Anesthesiology. 2013;119:824–36.

    Article  CAS  PubMed  Google Scholar 

  39. Marik PE, Monnet X, Teboul JL. Hemodynamic parameters to guide fluid therapy. Ann Intensive Care. 2011;1:1.

    Article  PubMed Central  PubMed  Google Scholar 

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Acknowledgments

We would like to acknowledge all the institutions and their staff who participated in the SAH PiCCO study, especially Prof. Eiji Isotani, MD, PhD (Department of Emergency and Critical Care Medicine, Tokyo Women’s Medical University Medical Center East) who is the director of the study. We are grateful to Prof. Hideo Yasunaga, MD, PhD (Department of and Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo) for assistance during the statistical review of the manuscript. Takashi Tagami received speaker honoraria from Tokibo Co., Ltd. (import trader of the PiCCO system) for educational lectures at Japanese scientific meetings. This study was not funded or sponsored by any organization.

Conflicts of interest

Kentaro Kuwamoto, Akihiro Watanabe, Kyoko Unemoto, Shoji Yokobori, Gaku Matsumoto, Yutaka Igarashi, and Hiroyuki Yokota declare that they have no conflicts of interest.

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Authors and Affiliations

  1. Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan

    Takashi Tagami, Akihiro Watanabe, Shoji Yokobori, Gaku Matsumoto, Yutaka Igarashi & Hiroyuki Yokota

  2. Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

    Takashi Tagami

  3. Department of Emergency and Critical Care Medicine, Nippon Medical School Tamanagayama Hospital, Tokyo, Japan

    Kentaro Kuwamoto & Kyoko Unemoto

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  1. Takashi Tagami
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  2. Kentaro Kuwamoto
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Correspondence to Takashi Tagami.

Additional information

Takashi Tagami and Kentaro Kuwamoto contributed equally to this work.

This study was conducted on behalf of the SAH PiCCO Study Group.

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Tagami, T., Kuwamoto, K., Watanabe, A. et al. Effect of Triple-H Prophylaxis on Global End-Diastolic Volume and Clinical Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 21, 462–469 (2014). https://doi.org/10.1007/s12028-014-9973-z

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