Perioperative blood pressure control of hypertensive ICH patients

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Perioperative blood pressure control of
hypertensive ICH patients
?????? ???
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Acute Postoperative HypertensionA review of
therapeutic option

• APH has an early onset, being observed within 2
  hours after surgery in most case.
• Occasionally, APH may persist for 2448 hours.
• Complications of APH
• Hemorrhagic stroke?cerebral
  ischemia?encephalopathy?
• myocardial ischemia?myocardial
  infarction?cardiac arrhythmia?congestive heart
  failure?
• Bleeding at the surgical site

Am J Health-Syst Pharm, 2004, Vol 61, 16611675
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Frequency of APH by Surgical Procedure
Procedure Frequency of APH()
Carotid endarteretomy 964
Cardiac Surgery 2254
Abdominal aortic surgery 3375
Radical neck dissection 1020
Intracrainal neurosurgery 5791
Elective general surgery 39
Elective surgery (noncardiac) 20
Release of flexion contractures 46
Am J Health-Syst Pharm, 2004, Vol 61, 16611675
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Guideline for the management of spontaneous
intracranial hemorrhage

1. Intracerebral hemorrhage is more than twice as
   common as subarachnoid hemorrhage(SAH) and is
   much more likely to result in death or major
   disability than cerebral infarction or SAH.
2. Advancing age and hypertension are the most
   important risk factor for ICH.

Stroke, 1999, 30905915
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Cause of intracranial hemorrhage

• Cerebral amyloid angiopathy for elder
• Vascular malformations
• Ruptured aneurysm
• Coagulation disorders
• Use of anticoagulant and thrombolytic agent
• hemorrhage into a cerebral infarction
• Bleeding into brain tumor
• Drug abuse

Stroke, 1999, 30905915
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Treatment of Acute ICH

• Airway and oxygenation
• Blood pressure management
• Management of increased ICP
• Fluid management
• Prevention of seizure
• Management of Body temperature

Stroke, 1999, 30905915
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Blood Pressure Management

1. In general, recommendations for treatment of
   elevated blood pressure in patients with ICH are
   more aggressive than those for patients with
   ischemic stroke.
2. Lowering blood pressure is to decrease the risk
   of ongoing bleeding from ruptured small arteries
   and arterioles.
3. Conversely, overaggressive treatment of blood
   pressure may decrease cerebral perfusion pressure
   and theoretically worsen brain injury,
   particularly in the setting of increased
   intracranial pressure.

Stroke, 1999, 30905915
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Goal of Acute ICH

• Mean Blood Pressurelt130 mmHg
• (MBPgt110 mmHg should be avoid in the
  immediate postoperative period)
• Cranial Perfusion Pressuregt70 mmHg
• Intracranial Pressurelt20 mmHg

Stroke, 1999, 30905915
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???? Blood pressure control and postoperative
recurrence of hypertensive brain hemorrhage
Hypertensive ICH (basal ganglion,subcortical) 2003
-2005 35 patient with postoperative
aggressive control BP (MBPlt 110,
DBPlt90) starting from OR to ICU 2002-2004
33 patient without active control BP gt 2
episodes (MBPgt110)
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35
33
3
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Therapeutic Approach to Vasospasm in Subarachnoid
Hemorrhage

• Rupture of a cerebral aneurysm
• gt50 Delayed vasospasm
• 1/3 Symptomatic ischemia
• gt20 Permanent deficits or death

Current Opinion in Critical Care, 2002, 8128133
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Treatment of Vasospasm
Outcome of delayed ischemic deficits(DID) Outcome of delayed ischemic deficits(DID) Outcome of delayed ischemic deficits(DID) Outcome of delayed ischemic deficits(DID) Outcome of delayed ischemic deficits(DID)
No. patients Dead Permanent deficit recovery
Natural history 3327 30.3 34.0 35.7
HHH treatment 2111 17.5 28.5 54.0
Nimodipine treatment
Continued from prophylaxis 445 18 32 50
De novo for DID 343 13 20 67
Nicardipine treatment 191 12 17 71
HHHHypervolemia, Hypertension, Hemodilution HHHHypervolemia, Hypertension, Hemodilution HHHHypervolemia, Hypertension, Hemodilution HHHHypervolemia, Hypertension, Hemodilution HHHHypervolemia, Hypertension, Hemodilution
Stroke, 1999, 30905915
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Ideal Therapeutic Agents to Treat
Perioperative Hypertension
1. Rapid onset of action 2. IV
administration 3. Titratable 4.
Vasodilator 5. Short half life
Am J Health-Syst Pharm, 2004, Vol 61, 16611675
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Anti-Hyperetensive Drugs

• Nitrates
• Nitroglycerin Sodium Nitroprusside
• Beta-Adrenergic Blockers
• Labetalol Esmolol
• Calcium Channel Blockers
• Diltiazem Nifedipine Nicardipine

Am J Health-Syst Pharm, 2004, Vol 61, 16611675
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????

1. ??? Nicardipine hydrochloride
2. ???

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Mechanism of Perdipine
? Interfere Ca2 Influx ? Vasodilation
? Avoid Intracellular Ca2 Accumulation
? Cellular Protection
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Perdipine Injection???
? ????????,?????? ? ????????,????? ?
???,??,??????????? ? ?????,????????? ?
???????,?????????
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Control Blood Pressure of Acute Cerebral
Hemorrhage

• 22 patients with acute cerebral hemorrhage
• 24 Hour1.14?0.45(range0.611.69) µg/kg/min
• 72 Hour0.60 ?0.45(range0.241.06) µg/kg/min

Before infusion 24h 72h
SBP(mmHg) 200 150 147
DBP(mmHg) 110 70 65
HR 95 85 82
ICP(mmHg) 30 20 20
PPC(mmHg) 99 75 73
Can J Anesth, 2000, 47(12) 11961201
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CT Finding
24h 72h 24h after the end of in fusion
Hemorrhage Increase 0 0 0
(Hematoma) No Change 4 3 1
Decrease 18 (82) 19 (86) 21 (95)
Edema Increase 0 0 0
No change 10 8 5
Decrease 12 (55) 14 (64) 17 (77)
Velocity of middle cerebral artery did not change
Can J Anesth, 2000, 47(12) 11961201
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Nicardipine as a Treatment for Cerebral Vasospasm

• 38 vessels in 18 patients with cerebral
  vasospasm,
• and treated with intra-arterial nicardipine
  0.1mg/ml, 5mg per vessel

baseline Before treat After treat
PSV(cm/s) 161.9 ?61.9 277.4 ?80.8 212.8 ?65.7
Vmean(cm/.s) 105.6 ?43.9 201.3 ?65.8 145.1 ?54.1
PSVPeak Systolic velocities PSVPeak Systolic velocities PSVPeak Systolic velocities PSVPeak Systolic velocities
AJNR Am J Neuroradiol, 2004, 25819826
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Perdipine Injection ???
????????????????, ?????????
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Perdipine Injection????? (?)
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Perdipine Injection????? (?)
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Perdipine Injection Contraindications
1. Patients with known hypersensitivity to the
drug. 2. Patients with suspected incomplete
hemostasis following intracranial
hemorrhage. 3. Patients with elevated
intracranial pressure at the acute stage of
cerebral stroke.
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Perdipine Injection Adverse Effects
?????634? ?????706?
??????? 34?(4.8)
???? 25 (3.5)
????? 5 (0.7)
???? 2 (0.3)
???? 1 (0.1)
???? 1(0.1)
???? 95.2
(???????)
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??,??????
? ??????,????????
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?????????
? ???????????
()
0
20
40
60
80
100
159 mmHg
71.0
160179 mmHg
80.8
180 mmHg
87.3
????
??
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Nicardipine Increased Cerebral Blood flow
? ???????
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Effects of Nicardipine in Coronary Artery Disease
? ??????COCBF
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Perdipine Injection ?????
?????? IV Bolus??????? ????1030
?g/kg ????1.52.5 mL (slow push),??? BP ??
2530,??? iv infusion ? ??????? ???????
IV Infusion??????510?g/kg/min,??????
5565mmHg ?,? ?????
1?g/kg/min ???????????? IV
Infusion????0.51.5 ?g/kg/min ??????? IV
Infusion??? 210 mg/hr,????????????? ??PDR,
2000????????????,???? 5mg/mL,? 15min??? 2.5mg/mL
(???????,?? 5min ????? 2.5mg/mL),???????
15mg/mL?
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• THANKS