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Perioperative blood pressure control of hypertensive ICH patients. 彰基神經外科 周啟文. APH has an early onset, being observed within 2 hours after surgery in most case. Occasionally, APH may persist for 24~48 hours . Complications of APH : Hemorrhagic stroke 、 cerebral ischemia 、 encephalopathy 。

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acute postoperative hypertension a review of therapeutic option
APH has an early onset, being observed within 2 hours after surgery in most case.

Occasionally, APH may persist for 24~48 hours.

Complications of APH:

Hemorrhagic stroke、cerebral ischemia、encephalopathy。

myocardial ischemia、myocardial infarction、cardiac arrhythmia、congestive heart failure。

Bleeding at the surgical site

Acute Postoperative Hypertension:A review of therapeutic option

Am J Health-Syst Pharm, 2004, Vol 61, 1661~1675

frequency of aph by surgical procedure
Frequency of APH by Surgical Procedure

Am J Health-Syst Pharm, 2004, Vol 61, 1661~1675

guideline for the management of spontaneous intracranial hemorrhage
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.

Advancing age and hypertension are the most important risk factor for ICH.

Guideline for the management of spontaneous intracranial hemorrhage

Stroke, 1999, 30:905~915

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

Cause of intracranial hemorrhage

Stroke, 1999, 30:905~915

treatment of acute ich
Airway and oxygenation

Blood pressure management

Management of increased ICP

Fluid management

Prevention of seizure

Management of Body temperature

Treatment of Acute ICH

Stroke, 1999, 30:905~915

blood pressure management
In general, recommendations for treatment of elevated blood pressure in patients with ICH are more aggressive than those for patients with ischemic stroke.

Lowering blood pressure is to decrease the risk of ongoing bleeding from ruptured small arteries and arterioles.

Conversely, overaggressive treatment of blood pressure may decrease cerebral perfusion pressure and theoretically worsen brain injury, particularly in the setting of increased intracranial pressure.

Blood Pressure Management

Stroke, 1999, 30:905~915

goal of acute ich
Mean Blood Pressure<130 mmHg

(MBP>110 mmHg should be avoid in the immediate postoperative period)

Cranial Perfusion Pressure>70 mmHg

Intracranial Pressure<20 mmHg

Goal of Acute ICH

Stroke, 1999, 30:905~915

blood pressure control and postoperative recurrence of hypertensive brain hemorrhage
彰基經驗 Blood pressure control and postoperative recurrence of hypertensive brain hemorrhage

Hypertensive ICH (basal ganglion,subcortical)

2003 -2005

35 patient with postoperative aggressive control BP

(MBP< 110, DBP<90) starting from OR to ICU

2002-2004

33 patient without active control BP > 2 episodes (MBP>110)

slide10

35

33

3

therapeutic approach to vasospasm in subarachnoid hemorrhage
Rupture of a cerebral aneurysm

>50% Delayed vasospasm

1/3 Symptomatic ischemia

>20% Permanent deficits or death

Therapeutic Approach to Vasospasm in Subarachnoid Hemorrhage

Current Opinion in Critical Care, 2002, 8:128~133

treatment of vasospasm
Treatment of Vasospasm

Stroke, 1999, 30:905~915

slide13

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, 1661~1675

slide14

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, 1661~1675

slide15

基本資料

  • 一般名 : Nicardipine hydrochloride
  • 結構式 :
slide16

Mechanism of Perdipine

◆ Interfere Ca2+ Influx

◆ Vasodilation

◆ Avoid Intracellular Ca2+ Accumulation

◆ Cellular Protection

slide17

Perdipine Injection的特性

◆迅速發揮降壓效果,維持穩定血壓

◆ 不會過度降低血壓,易調節用量

◆ 增加腦,心臟,腎臟等重要臟器的血流量

◆ 有利尿作用,可維持麻醉時的尿量

◆ 除了靜脈滴注外,還可作直接靜脈注射

control blood pressure of acute cerebral hemorrhage
Control Blood Pressure of Acute Cerebral Hemorrhage

22 patients with acute cerebral hemorrhage

24 Hour:1.140.45(range:0.61~1.69) μg/kg/min

72 Hour:0.60 0.45(range:0.24~1.06) μg/kg/min

Can J Anesth, 2000, 47(12) :1196~1201

ct finding
CT Finding

Velocity of middle cerebral artery did not change

Can J Anesth, 2000, 47(12) :1196~1201

nicardipine as a treatment for cerebral vasospasm
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

AJNR Am J Neuroradiol, 2004, 25:819~826

slide21

Perdipine Injection

適應症

適用於當口服治療不可行或不合適時,

對高血壓的短期處置

slide24

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.

slide25

Perdipine Injection

Adverse Effects

總投藥病例634例 總投藥次數706次

無副作用

95.2%

(山之內製藥統計)

slide26

血壓,心搏數的變化

 維持穩定血壓,不會過度降低血壓

slide27

投藥前收縮壓別效果

 血壓愈高降壓效果愈顯著

(%)

0

20

40

60

80

100

~159 mmHg

71.0

160~179 mmHg

80.8

180 mmHg ~

87.3

顯著效果

有效

slide29

Effects of Nicardipine in Coronary

Artery Disease

 有意義的增加CO&CBF

slide30

Perdipine Injection 之詳細用量

高血壓之控制

IV Bolus:迅速將血壓降下 建議劑量:10~30 g/kg

常用劑量:1.5~2.5 mL (slow push),約可使 BP 降低 25~30%,可再以 iv infusion 投

藥持續控制血壓

手術時低壓控制

IV Infusion:常用起始劑量:5~10g/kg/min,待血壓控制於 55~65mmHg 時,再

降低劑量至 1g/kg/min

預防心或腦部之缺血、痙攣

IV Infusion:通常使用0.5~1.5 g/kg/min

使用於血管痙攣

IV Infusion:先投予 2~10 mg/hr,再依照血壓監測結果調整劑量

根據PDR, 2000:針對降血壓而給與的劑量為,起始劑量 5mg/mL,每 15min可增加 2.5mg/mL

(若須快速降血壓,則每 5min 可增加劑量 2.5mg/mL),最大劑量可達到 15mg/mL。