Abstract
Sixty eight consecutive patients with subarachnoid hemorrhage were managed according to the protocol of prophylactic isovolemic hemodilution therapy (PIH) using the Swan-Ganz catheter (S-G) for spasm between November 1988 and September 1990. Aneurysm surgery was performed on fifty five patients between day 0 and 3; 7 were operated on after day 4 and 6 were not operated on. All patients underwent placement of an S-G as soon as possible and were treated until day 14 with PIH. Pulmonary artery wedge pressure (PWP) of 10mmHg and right atrial pressure (RA) of 5mmHg were presumed as isovolemia, and optimal hemodilution was determined to be 32%of hematocrit (Ht). Isovolemic hemodilution (IH) was induced just after the first hemodynamic study and maintained by administration of hemodiluting agents such as fresh frozen plasma (FFP) or low molecular weight dextran. According to early experience with symptomatic spasm (SS), the protocol was slightly changed. Rather than PWP and RA, the cardiac index (CI) was thought to be more important and was maintained above 51/min/m2 by administration of Dobutamine (Hyperdynamic therapy: HD) or/and Nicardipine (Vasodilatation therapy: VD) in reference to systemic vascular resistance index, when it was inadequately elevated by those of IH alone.
Results showed that most of the postoperative patients were in a hypovolemic state, few patients showed low CI even without cardiac disease and PIH combined with HD or/and VD resulted in low incidence of SS and cerebral infarction following spasm. Especially in patients younger than 70 years old with Fisher group 3 SAH, PIH combined with HD or/and VD reduced SS and cerebral infarction in half of IH using a central venous pressure catheter with which patients had been managed before October 1988 (SS: 32.1%vs 62.9%, infarction: 14.3%vs 31.4%).
Several complications occurred, which were divided into those of S-G and IH. The former were pneumothorax, hemothorax at the insertion, which did not occur after changing the insertion site from the subclavian vein to the internal jugular vein, and arryhthmia at the insertion and while the catheter was in place. The latter, which might become serious, were pulmonary emboli (1 case, which improved with medical therapy) and non-A non-B hepatitis (4/54 cases which we were able to follow for 3 months; 3 patients improved, 1 is still in therapy).
This study shows that although hemodynamic management using S-G is effective for preventing SS, serious-but low rate-complications related to S-G and FFP may occur. Protocol have to be changed in selection of patients, placing of S-G, hemodiluting agents and duration of catheterization
