Hemodynamic Augmentation

Currently the mainstay of treatment of symptomatic vasospasm in patients with repaired aneurysms is hemodynamic augmentation (HA). HA consists of some combination of large volumes of fluids, vasopressors, and inotropic agents; however, the optimal combination is unknown. This intervention has never been tested in a randomized, controlled setting and is based on a number of case series that focused on different aspects of HA.

Once the threshold for aggressive treatment has been crossed, any possible hypovolemia should be corrected rapidly. The use of colloids is controversial, with no clear data to support their efficacy. Although it appears that the correction of hypovolemia is important, no data clearly indicate benefits of hypervolemia over euvolemia. Some degree of acute volume expansion may be helpful in improving cardiac output and blood pressure, but this effect in one study plateaued at pulmonary capillary wedge pressure of 14 mmHg (86). If fluid administration produces no immediate response, vasoactive agents should be employed, either inotropic agents (dobuta-mine) to improve cardiac output or vasopressors (phenylephrine) or combined agents (dopamine and norepinephrine) to augment systemic blood pressure.

At issue is the hemodynamic parameter that is best to augment. One approach is to place a pulmonary artery catheter to determine which parameter is most amenable to augmentation. Use of a Swan-Ganz catheter is also helpful in patients with cardiac disease to help guide therapy and prevent fluid overload or congestive heart failure. Although preliminary reports indicated a high complication rate with this therapy, subsequent studies have found that, with close monitoring, complications were low (87).

The major focus of all of these therapeutic maneuvers is to improve neurologic function. If a hemodynamic goal is reached, but no neurologic improvement is observed, the therapeutic maneuver should be reassessed. It should be emphasized that the use of hypertensive therapy is usually not recommended in patients with unclipped aneurysms. The use of HA appears safe in patients with recently coiled aneurysms (88). Weaning hemodynamic augmentation should be performed gradually, usually over several days, the rate of withdrawal being guided, again, by the neurologic status.

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