Reduce Complications in Subarachnoid Hemorrhage with PiCCO

  • Goal-Directed hemodynamic management leads to better prognosis for patients with Subarachnoid Hemorrhage (SAH) compared to standard therapy
  • Time to reach hemodynamic goals in the PiCCO group shorter than in the standard group
  • Avoid fluid overload with Extravascular Lung Water Index (EVLWI) as a warning parameter 

 

 

  • Parameter
  • Therapy
  • Indications
  • goal-directed Management
  • Literature

Overview of Essential Hemodynamic PiCCO Parameters

Get Answers to Essential Therapeutic Questions with PiCCO

  • Does the patient have adequate organ (esp. brain) perfusion?
    >> MAP / CI
  • Volume Management: What is the patient’s preload?
    >> GEDI
  • Is my patient volume responsive?
    >> SVV / PPV
  • When should we STOP giving fluids?
    >> ELWI
  • What is the myocardial condition?
    >> GEF, CFI, dPmx
  • Does the patient have pulmonary edema?
    >> ELWI
  • Is it pressure- or permeability-pulmonary edema?
    >> PVPI 

Indications and medical Complications

Pathophysiological Conditions / Typical Medical Complications:
  • Vasospasm as a major complication after SAH which can lead to Delayed Cerebral Ischemia (DCI)
  • Raised intracranial pressure due to intracranial hematoma is the most important complication in TBI
  • Myocardial dysfunction (e.g. “stunned myocardium”, Tako-Tsubo Syndrome), arrhythmias and tachycardia
  • Neurogenic pulmonary edema (NPE)
  • Electrolyte disorders, hyperglycemia, salt-wasting syndrome, etc.
  • Hypovolemia as one of the most significant risk factors for DCI(2)
PiCCO is used successfully in several neurological indications:
  • Subarachnoid Hemorrhage (SAH)
  • Intracranial Hemorrhage (ICH)
  • Traumatic Brain Injuries (TBI)
  • Acute Ischemic Stroke (AIS)
  • High-risk tumour surgery

Goal-directed Hemodynamic Management with PiCCO in SAH

Precise Volume Management: Where do we stand?

Especially in SAH patients with considerable volume shifts, fluid balance goals should constantly be assessed for the prevention of vasospasm and DCI(3). Whether hypervolemia (triple H concept) or normovolemia (hyperdynamic concept) is targeted – PiCCO is your guide in hemodynamic management.

  • GEDI is a reliable and validated parameter for preload. It better predicts fluid responsiveness compared to CVP or PCWP(1)
  • SVV provides information about volume responsiveness in ventilated neurosurgical patients. According to studies a SVV value of 9.5% or more predicted a SV increase of at least 5%(4). Furthermore SVV ≥ 9% is a good predictor of PbrO2 response(5)
  • ELWI can serve as a warning parameter for volume overload

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Manage Myocardial Dysfunction and Perfusion Pressures with the Right Dosage of Vasopressors and Inotropes.

Many patients with acute brain injuries (esp. SAH) develop myocardial dysfunction which requires the use of vasopressors and inotropes. With its broad spectrum of parameters the PiCCO gives a clear picture which allows optimal titration, and frequently, minimization of the dosage of inotropes and vasopressors.

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Monitor Neurogenic Pulmonary Edema



Neurogenic Pulmonary Edema (NPE) is considered to be an underdiagnosed condition. Studies show that approx. 71 % of fatal cases of SAH are complicated by NPE(6). ELWI is a unique lung water parameter which gives a more precise bedside assessment of pulmonary edema than chest X-Rays. The Pulmonary Vascular Permeability Index (PVPI) distinguishes between cardiogenic (PVPI < 3) or permeability pulmonary edema (PVPI > 3).







  • Mutoh T et al., Performance of Bedside Transpulmonary Thermodilution Monitoring for Goal-Directed Hemodynamic Management After Subarachnoid Hemorrhage. Stroke 2009, 40(7):2368 - 2374.
  • Hoff R et al., Blood Volume Measurement to Guide Fluid Therapy After Aneurysmal Subarachnoid Hemorrhage - A Prospective Controlled Study. Stroke 2009 40(7):2575-7.
  • Caplan JM et al., Managing subarachnoid hemorrhage in the neurocritical care unit. Neurosurg Clin N Am. 2013;24(3):321-37.
  • Berkenstadt H et al., Stroke volume variation as a predictor of fluid responsiveness in patients undergoing brain surgery. Anesth Analg 2001, 92(4):984-989.
  • Kurtz P et al., Fluid Responsiveness and Brain Tissue Oxygen Augmentation After Subarachnoid Hemorrhage. Neurocritical care 2014, 20(2):247-254.
  • Piazza O et al., Neurogenic pulmonary edema in subarachnoid hemorrhage. Panminerva Med. Sep 2011;53(3):203-10.
  • Baumann A et al., Neurogenic pulmonary edema. Acta Anaesthesiol Scand 2007; 51: 447–45.
  • Caplan JM et al., Managing Subarachnoid Hemorrhage in the Neurocritical Care Unit. Neurosurg Clin N Am 2013;24(3):321-37.
  • NICE-SUGAR Study Investigators, Finfer S et al., Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360(13):1283–97.

Webinar - Practical application of the PiCCO-Technology in the Neuro ICU

Thursday, 23. October 2014, 17:00 – 18:00 h (CEST)

Prof. Kees H. Polderman, Professor of Critical Care Medicine (Department of Critical Care Medicine, University of Pittsburgh Medical Center, USA)