gms | German Medical Science

To estimate practical usefulness of pulse contour and transpulmonary thermodilutiuon monitoring (PiCCO, Pulsion Medical Systems, Munich) in the hypervolemic hypertension hemodilution ('triple H') therapy for cerebral vasospasm after severe subarachnoid hemorrhage (SAH).

A consecutive group of 20 patients after SAH who developed cerebral vasospasm was treated with aggressive 'triple H' therapy under PiCCO monitoring which demands availability of a central venous line and insertion of an arterial catheter with an embedded thermistor. It provides intermittent (transpulmonary thermodilution-derived) and continuous (pulse contour-derived) assessment of cardiac systolic function [cardiac output (CO), stroke volume (SV) and global ejection fraction (GEF)] and estimations of cardiac pre- and afterloads [e.g. global end-diastolic volume (GEDV), extravascular lung water (ELW), pulmonary vascular permeability index (PVPI) and systemic vascular resistance (SVR)]. These indices have been used to adjust the cathecholamine and volume management to prevent lung edema, hemodynamic failure during septic shock and/or multiorgan failure and to provide the optimal oxygenation in mechanically ventilated patients.

One of 20 patients had SAH of Hunt and Hess grade II, n=12 were classified as grade III and n=7 as grade IV. In all, catecholamine therapy was established to treat or prevent hypoxic complications of vasospasm. No patient had mean arterial pressure <90 mm Hg or a cerebral perfusion pressure <65 mm Hg during therapy. There has been a significant consistency between the pulse-contour and thermodilution-derived parameters. The CO index ranged from 2 to 7 (median 4) l/min/m², the GEF ranged from 11 to 39%, the SVR index ranged from 1543 to 4425 (median 2129) dyn×s×cm^-5×m², the ELW index was within 5 and 19.5 (median 8) ml/kg and the ITBV index ranged from 521 and 1247 (median 816) ml/m². CO index was highly sensitive in the detection of hemodynamic changes but was less specific in determination of their origin (myocardial ischemia, septic shock, pulmonary edema etc.). One patient died of myocardial infarction, two sustained severe sepsis. Pulmonary edema could be early diagnosed in 5 cases by means of increased ELW index.

PiCCO is a minimally invasive tool for hemodynamic monitoring which may assist in the management of SAH-induced vasospasm and might be helpful for prediction of potential life-threatening complications of aggressive 'triple H' therapy.