Sunday, January 18, 2015

Q: Though debatable but one treatment for symptomatic vasospasm after Subarachnoid Hemorrhage (SAH) is "triple H therapy" (hypertension, hypervolemia, and hemodilution). It is recommended to 'float swan' (insertion of Pulmonary Artery Catheter) to guide volume expansion and inotropic or vasopressor therapy. What is the recommended "wedge pressure" (pulmonary artery occlusion pressure) is such cases?

Answer:  Pulmonary artery wedge pressure (PAWP) should be maintained at 14-20 mm Hg. If 'swan' is not inserted than Central venous pressure (CVP) should be maintained at least at 10-12 mm Hg. 

Treatment for symptomatic vasospasm after Subarachnoid Hemorrhage has traditionally involved the application of hypertension, hypervolemia, and hemodilution, or triple H therapy. Though, the efficacy of triple H therapy remains subject to debate. Aggressive hypertensive therapy with inotropes and vasopressors can be initiated. Hypervolemia is  achieved by using pRBCs, isotonic crystalloid, and colloid. Hemodilution is targeted to maintain the hematocrit at 30-35% in order to optimize blood viscosity.


Dankbaar JW, Slooter AJ, Rinkel GJ, Schaaf IC. Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review. Crit Care. 2010;14(1):R23. 

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