Sivakumar Sanjeev, Lazaridis Christos
Department of Neurology, Prisma Health-Upstate, University of South Carolina, Greenville, SC, USA.
Departments of Neurology and Neurosurgery, The University of Chicago, Chicago, IL, USA.
Crit Care Res Pract. 2020 Sep 15;2020:2748181. doi: 10.1155/2020/2748181. eCollection 2020.
Management of volume status, arterial blood pressure, and cardiac output are core elements in approaching the patients with aneurysmal subarachnoid hemorrhage (SAH). For the prevention and treatment of delayed cerebral ischemia (DCI), euvolemia is advocated and caution is made towards the avoidance of hypervolemia. Induced hypertension and cardiac output augmentation are the mainstays of medical management during active DCI, whereas the older triple-H paradigm has fallen out of favor due to lack of demonstrable physiological or clinical benefits and serious concern for adverse effects such as pulmonary edema and multiorgan system dysfunction. Furthermore, insight into clinical hemodynamics of patients with SAH becomes salient when one considers the frequently associated cardiac and pulmonary manifestations of the disease such as SAH-associated cardiomyopathy and neurogenic pulmonary edema. In terms of fluid and volume targets, less attention has been paid to dynamic markers of fluid responsiveness despite the well-established, in the general critical care literature, superiority of these as compared to traditionally used static markers such as central venous pressure (CVP). Based on this literature and sound pathophysiologic reasoning, reliance on static markers (such as CVP) is unjustified when one attempts to assess strategies augmenting stroke volume (SV), arterial blood pressure, and oxygen delivery. There are several options for continuous bedside cardiorespiratory monitoring and optimization of SAH patients. We, here, review a noninvasive monitoring technique based on thoracic bioreactance and focusing on continuous cardiac output and fluid responsiveness markers.
容量状态、动脉血压和心输出量的管理是处理动脉瘤性蛛网膜下腔出血（SAH）患者的核心要素。为预防和治疗迟发性脑缺血（DCI），提倡等容状态，并谨慎避免高血容量。在DCI活动期，诱导性高血压和心输出量增加是药物治疗的主要手段，而传统的“三高”（高血压、高血容量、血液稀释）治疗模式因缺乏明显的生理或临床益处以及对肺水肿和多器官系统功能障碍等不良反应的严重担忧而失宠。此外，当考虑到SAH患者常见的心脏和肺部表现，如SAH相关性心肌病和神经源性肺水肿时，对SAH患者临床血流动力学的了解就变得尤为重要。在液体和容量目标方面，尽管在一般重症监护文献中已证实，与传统使用的静态指标如中心静脉压（CVP）相比，液体反应性的动态指标更具优势，但人们对其关注较少。基于这些文献和合理的病理生理推理，当试图评估增加每搏输出量（SV）、动脉血压和氧输送的策略时，依赖静态指标（如CVP）是不合理的。对于SAH患者的床边连续心肺监测和优化有多种选择。在此，我们回顾一种基于胸段生物电阻抗的非侵入性监测技术，该技术专注于连续心输出量和液体反应性指标。
