Role of Vasopressor Administration in Patients with Acute Neurologic Injury
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REVIEW ARTICLE
Role of Vasopressor Administration in Patients with Acute Neurologic Injury Katie M. Muzevich Æ Stacy A. Voils
Published online: 22 April 2009 Ó Humana Press Inc. 2009
Abstract Introduction Pharmacologic blood pressure elevation is often utilized to prevent or treat ischemia in patients with acute neurologic injury, and routinely requires administration of vasopressor agents. Depending on the indication, vasopressor agents may be administered to treat hypotension or to induce hypertension. Methods Although numerous guideline statements exist regarding the management of blood pressure in these patients, most recommendations are based largely on Class III evidence. Further, there are few randomized controlled trials comparing vasopressor agents in these patients and selection is often guided by expert consensus. Results We discuss the clinical evidence regarding vasopressor administration for blood pressure management in patients with acute neurologic injury. The effect of various vasopressors on cerebral hemodynamics is also discussed. Conclusion Although high-quality clinical data are scarce, the available evidence suggests that norepinephrine should be considered as the vasopressor of choice when blood pressure elevation is indicated in patients with acute neurologic injury. Keywords Vasopressor Neurologic injury Stroke Subarachnoid hemorrhage Traumatic brain injury Carotid injury Spinal cord injury Hypertension Blood pressure
Introduction Vasopressor administration is often utilized concurrently with fluid resuscitation in patients with acute neurologic injury to maintain or augment perfusion to areas of injury. Clinical outcomes may be poor when hypotension occurs in these patients. For example, a single systolic blood pressure of 130 mmHg) in patients with secured aneurysms [13, 14] (Table 3). Prophylactic induced hypertension as a component of triple H therapy has not been shown to decrease the incidence of DIND and should be discouraged [15–18]. Additionally, triple H therapy is not without potential risk. Myocardial ischemia, pulmonary edema, and heart failure have been reported and thus frequent assessment of cardiac enzymes, electrocardiograph, arterial blood pressure, fluid balance, chest X-ray, and central venous pressure should be performed to monitor for adverse effects related to triple H therapy [13]. The most commonly used vasopressors for triple H therapy are phenylephrine, dopamine, and norepinephrine, all of which have been shown to increase regional cerebral blood flow in SAH patients with ischemia [12]. Some authors recommend choice of vasopressor should depend on patient factors. For instance, patients with tachycardia at baseline should receive phenylephrine due to propensity to induce a reflex bradycardia. Conversely, patients with baseline bradycardia due to Cushing’s reflex may benefit more from mixed alpha and beta agonists, such as norepinephrine and dopamine. Prospective comparative studies regarding vasopressor selection are lacking in this population.
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