Busani Stefano, Rinaldi Laura, Severino Claudia, Cobelli Milena, Pasetto Alberto, Girardis Massimo
Cattedra e Servizio di Anestesia e Rianimazione I, Policlinico di Modena, Università di Modena e Reggio Emilia, Modena, Italy.
J Trauma. 2010 May;68(5):E108-10. doi: 10.1097/TA.0b013e31817c4284.
The aim of this study is to report the development of cardiac failure after subarachnoid hemorrhage (SAH) with recovery of heart and cerebral function. This is a case report of a 38-year-old woman who was admitted to the intensive care unit (ICU) at Policlinico di Modena, Italy. This woman developed a deep state of coma because of severe SAH. After cerebral hemorrhage, patient showed a cardiogenic shock, which needed invasive monitoring. Cerebral perfusion pressure had to be restored, so fluids, dopamine, norepinephrine, and dobutamine were in administered sequentially. Despite these supportive treatments, hemodynamic parameters further worsened and echocardiography showed a global depressed left ventricular (LV) contraction with poor ejection fraction (EF) and restrictive type of LV relaxation pattern. Twenty-four hours after ICU admission, levosimendan was started with the aim to improve cardiac function because of the refractoriness of all other treatments. Eight hours after levosimendan infusion, cardiac function improved and, within the after 24 hours, EF and LV relaxation pattern recovered. Neurologic state and computed tomography images improved day by day, and after 9 days from the ICU admission, we transferred the patient to the neurosurgical ward with very good neurologic conditions and no deficits in motility. The conventional management of post-SAH cardiovascular failure is based on the use of norepinephrine, dobutamine, and high amount of fluids. This strategy did not provide any improvement, so we decided for levosimendan infusion to counteract myocardial stunning. The improvement in cardiac EF, LV wall motion, and filling pressure observed in our patient could be explained due to the antistunning triple-mechanism action of levosimendan. Data available on the levosimendan effectiveness in patients with SAH and its effect on intracranial pressure are still lacking, but we think that neurogenic cardiac failure can be treated at first with levosimendan.
本研究旨在报告蛛网膜下腔出血（SAH）后出现心力衰竭并伴有心脏和脑功能恢复的情况。这是一例38岁女性的病例报告，该女性被收入意大利摩德纳综合医院的重症监护病房（ICU）。该女性因严重SAH陷入深度昏迷状态。脑出血后，患者出现心源性休克，需要进行有创监测。必须恢复脑灌注压，因此依次给予液体、多巴胺、去甲肾上腺素和多巴酚丁胺。尽管采取了这些支持性治疗措施，血流动力学参数仍进一步恶化，超声心动图显示左心室（LV）整体收缩功能减退，射血分数（EF）降低，LV舒张模式呈限制性。入住ICU 24小时后，由于其他所有治疗均无效，开始使用左西孟旦以改善心脏功能。左西孟旦输注8小时后，心脏功能改善，24小时内心脏EF和LV舒张模式恢复。神经系统状态和计算机断层扫描图像逐日改善，入住ICU 9天后，我们将患者转至神经外科病房，患者神经状态良好，无运动功能缺损。SAH后心血管衰竭的传统治疗方法是使用去甲肾上腺素、多巴酚丁胺和大量液体。这种策略没有带来任何改善，因此我们决定输注左西孟旦以对抗心肌顿抑。我们患者中观察到的心脏EF、LV壁运动和充盈压的改善可以用左西孟旦的抗顿抑三重机制作用来解释。关于左西孟旦对SAH患者有效性及其对颅内压影响的数据仍然缺乏，但我们认为神经源性心力衰竭可以首先用左西孟旦进行治疗。
