Current practices of triple-H prophylaxis and therapy in patients with subarachnoid hemorrhage

Rachel Meyer, Steven Deem, Norbert Yanez, Michael Souter, Arthur Lam, Miriam Treggiari

Research output: Contribution to journalArticle

56 Citations (Scopus)

Abstract

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Original languageEnglish (US)
Pages (from-to)24-36
Number of pages13
JournalNeurocritical Care
Volume14
Issue number1
DOIs
StatePublished - Feb 2011
Externally publishedYes

Fingerprint

Subarachnoid Hemorrhage
Intracranial Vasospasm
Hemodilution
Blood Pressure
Hypertension
Therapeutics
Indwelling Catheters
Central Venous Catheters
Phenylephrine
Therapeutic Uses
Surveys and Questionnaires
Norepinephrine
Arterial Pressure
Guidelines

Keywords

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

ASJC Scopus subject areas

  • Clinical Neurology
  • Critical Care and Intensive Care Medicine

Cite this

Current practices of triple-H prophylaxis and therapy in patients with subarachnoid hemorrhage. / Meyer, Rachel; Deem, Steven; Yanez, Norbert; Souter, Michael; Lam, Arthur; Treggiari, Miriam.

In: Neurocritical Care, Vol. 14, No. 1, 02.2011, p. 24-36.

Research output: Contribution to journalArticle

Meyer, Rachel ; Deem, Steven ; Yanez, Norbert ; Souter, Michael ; Lam, Arthur ; Treggiari, Miriam. / Current practices of triple-H prophylaxis and therapy in patients with subarachnoid hemorrhage. In: Neurocritical Care. 2011 ; Vol. 14, No. 1. pp. 24-36.
@article{23b3aaa34ef34aeeae745ec346ec8d6f,
title = "Current practices of triple-H prophylaxis and therapy in patients with subarachnoid hemorrhage",
abstract = "Background: 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. Methods: 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. Results: 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. Conclusions: 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.",
keywords = "Cerebral vasospasm, Delayed ischemic neurologic deficit, Human, Induced hypertension, Subarachnoid hemorrhage, Triple-H therapy, Volume expansion",
author = "Rachel Meyer and Steven Deem and Norbert Yanez and Michael Souter and Arthur Lam and Miriam Treggiari",
year = "2011",
month = "2",
doi = "10.1007/s12028-010-9437-z",
language = "English (US)",
volume = "14",
pages = "24--36",
journal = "Neurocritical Care",
issn = "1541-6933",
publisher = "Humana Press",
number = "1",

}

TY - JOUR

T1 - Current practices of triple-H prophylaxis and therapy in patients with subarachnoid hemorrhage

AU - Meyer, Rachel

AU - Deem, Steven

AU - Yanez, Norbert

AU - Souter, Michael

AU - Lam, Arthur

AU - Treggiari, Miriam

PY - 2011/2

Y1 - 2011/2

N2 - Background: 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. Methods: 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. Results: 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. Conclusions: 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.

AB - Background: 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. Methods: 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. Results: 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. Conclusions: 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.

KW - Cerebral vasospasm

KW - Delayed ischemic neurologic deficit

KW - Human

KW - Induced hypertension

KW - Subarachnoid hemorrhage

KW - Triple-H therapy

KW - Volume expansion

UR - http://www.scopus.com/inward/record.url?scp=79551551802&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=79551551802&partnerID=8YFLogxK

U2 - 10.1007/s12028-010-9437-z

DO - 10.1007/s12028-010-9437-z

M3 - Article

C2 - 20838932

AN - SCOPUS:79551551802

VL - 14

SP - 24

EP - 36

JO - Neurocritical Care

JF - Neurocritical Care

SN - 1541-6933

IS - 1

ER -