Indian Journal of Critical Care Medicine

Register      Login

SEARCH WITHIN CONTENT

FIND ARTICLE

Volume / Issue

Online First

Archive
Related articles

VOLUME 27 , ISSUE 4 ( April, 2023 ) > List of Articles

Original Article

The Effect of Pharmacologically Induced Blood Pressure Manipulation on Cardiac Output and Cerebral Blood Flow Velocity in Patients with Aneurysmal Subarachnoid Hemorrhage

Manjunatha Lakshmegowda, Radhakrishnan Muthuchellapan, Megha Sharma, S Umamaheswara Rao Ganne, Dhritiman Chakrabarti, Sindhupriya Muthukalai

Keywords : Blood pressure, Cardiac output, Cerebral blood flow velocity, Cerebral vasospasm, Subarachnoid Hemorrhage, Transcranial Doppler

Citation Information : Lakshmegowda M, Muthuchellapan R, Sharma M, Ganne SU, Chakrabarti D, Muthukalai S. The Effect of Pharmacologically Induced Blood Pressure Manipulation on Cardiac Output and Cerebral Blood Flow Velocity in Patients with Aneurysmal Subarachnoid Hemorrhage. Indian J Crit Care Med 2023; 27 (4):254-259.

DOI: 10.5005/jp-journals-10071-24435

License: CC BY-NC 4.0

Published Online: 31-03-2023

Copyright Statement:  Copyright © 2023; The Author(s).


Abstract

Background: Vasopressors are used in patients with subarachnoid hemorrhage (SAH) to increase blood pressure with the idea of reversing the ischemic process. The current study is designed to evaluate the changes in systemic and cerebral hemodynamics, including cerebral blood flow autoregulation, at different pharmacologically augmented blood pressure levels using norepinephrine in patients with spontaneous aneurysmal SAH following surgery. Materials and methods: This prospective observational study was carried out in patients with ruptured anterior circulation aneurysms who underwent surgical clipping and required norepinephrine infusion. Postoperatively, when the treating physician decided to start a vasopressor, norepinephrine infusion was started at 0.05 µg/kg/min. The infusion rate was increased by 0.05 µg/kg/min every 5 minutes to achieve a 20% and then 40% increase in the systolic blood pressure (SBP). When the blood pressure stabilized at each level for 5 minutes, hemodynamic and transcranial doppler (TCD) parameters in the middle cerebral artery (MCA) were recorded. Results: Peak systolic, end-diastolic, and mean flow velocities in the MCA increased with targeted blood pressure increase in the hemispheres with impaired autoregulation and not in the hemispheres with intact autoregulation. The interaction of changes in TCD flow velocities between hemispheres with and without intact autoregulation was significant (p < 0.001). Cardiac output changes following norepinephrine infusion were not significant (p = 0.113). Conclusion: Hypertensive therapy with norepinephrine increases cerebral blood flow velocity only when autoregulation is impaired, an effect that is desirable in patients with focal cerebral ischemia following SAH.


HTML PDF Share
  1. Moppett I, Wild MJ, Sherman RW, Latter JA, Miller K, Mahajan RP. Effects of ephedrine, dobutamine and dopexamine on cerebral haemodynamics: Transcranial doppler studies in healthy volunteers. Br J Anaesth 2004;92(1):39–44. DOI: 10.1093/bja/aeh014.
  2. Moppett I, Sherman R, Wild M, Latter JA, Mahajan RP. Effects of norepinephrine and glyceryl trinitrate on cerebral haemodynamics: Transcranial doppler study in healthy volunteers. Br J Anaesth 2008;100(2):240–244. DOI: 10.1093/bja/aem374.
  3. Athar MK, Levine JM. Treatment Options for Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage. Neurotherapeutics 2012;9(1):37–43. DOI: 10.1007/s13311-011-0098-1.
  4. Muench E, Horn P, Bauhuf C, Roth H, Philipps M, Hermann P, 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(8):1844–1851. DOI: 10.1097/01.CCM.0000275392.08410.DD.
  5. Raabe A, Beck J, Keller M, Vatter H, Zimmermann M, Seifert V. Relative importance of hypertension compared with hypervolemia for increasing cerebral oxygenation in patients with cerebral vasospasm after subarachnoid hemorrhage. J Neurosurg 2005;103:974–981. DOI: 10.3171/jns.2005.103.6.0974.
  6. Otsubo H, Takemae T, Inoue T, Kobayashi S, Sugita K. Normovolaemic induced hypertension therapy for cerebral vasospasm after subarachnoid haemorrhage. Acta Neurochir 1990;103:18–26. DOI: 10.1007/BF01420187.
  7. Muizelaar JP, Becker DP. Induced hypertension for the treatment of cerebral ischemia after subarachnoid hemorrhage. Direct effect on cerebral blood flow. Surg Neurol 1986;25(4):317–325. DOI: 10.1016/0090-3019(86)90205-3.
  8. Origitano TC, Wascher TM, Reichman OH, Anderson DE. Sustained increased cerebral blood flow with prophylactic hypertensive hypervolemic hemodilution (“triple-H” therapy) after subarachnoid hemorrhage. Neurosurgery 1990;27(5):729–739. DOI: 10.1097/00006123-199011000-00010.
  9. Joseph M, Ziadi S, Nates J, Dannenbaum M, Malkoff M. Increases in cardiac output can reverse flow deficits from vasospasm independent of blood pressure: A study using xenon computed tomographic measurement of cerebral blood flow. Neurosurgery 2003;53(5): 1044–1051. DOI: 10.1227/01.NEU.0000088567.59324.78.
  10. Aaslid R, Markwalder T, Nornes H. Noninvasive transcranial doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 1982;57(6):769–774. DOI: 10.3171/jns.1982.57.6.0769.
  11. Squara P, Denjean D, Estagnasie P, Brusset A, Dib JC, Dubois C. Noninvasive cardiac output monitoring (NICOM): A clinical validation. Intensive Care Med 2007; 33(7):1191–1194. DOI: 10.1007/s00134-007-0640-0.
  12. Raval N, Squara P, Cleman M, Yalamanchili K, Winklmaier M, Burkhoff D. Multicenter evaluation of noninvasive cardiac output measurement by bioreactance technique. J Clin Monit Comput 2008;22:113–119. DOI: 10.1007/s10877-008-9112-5.
  13. Moppett I, Mahajan RP. Transcranial doppler ultrasonography in anaesthesia and intensive care. Br J Anaesth 2004;93(5):710–724. DOI: 10.1093/bja/aeh205.
  14. Budohoski KP, Czosnyka M, Smielewski P, Varsos GV, Kasprowicz M, Brady KM, et al. Cerebral autoregulation after subarachnoid hemorrhage: Comparison of three methods. J Cereb Blood Flow Metab 2013;33(3):449–456. DOI: 10.1038/jcbfm.2012.189.
  15. McGregor D, Sharma S, Gupta S, Ahmad S, Godec T, Harris T. Emergency department noninvasive cardiac output study (EDNICO): A feasibility and repeatability study. Scand J Trauma Resusc Emerg Med 2019;27(1):30. DOI: 10.1186/s13049-019-0586-6.
  16. Doherty A, El-Khuffash A, Monteith C, McSweeney L, Breatnach C, Kent E, et al. Comparison of bioreactance and echocardiographic non- invasive cardiac output monitoring and myocardial function assessment in primagravida women. Br J Anaesth 2017;118(4): 527–532. DOI: 10.1093/bja/aex045.
  17. Engquist H, Rostami E, Ronne-Engström E, Nilsson P, Lewén A, Enblad P. Effect of HHH-Therapy on Regional CBF after Severe Subarachnoid Hemorrhage Studied by Bedside Xenon-Enhanced CT. Neurocrit Care 2018;28:143–151. DOI: 10.1007/s12028-017-0439-y.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.