Transcript 無投影片標題
Perioperative blood pressure control of hypertensive ICH patients 彰基神經外科 周啟文 Acute Postoperative Hypertension： A review of therapeutic option 1. APH has an early onset, being observed within 2 hours after surgery in most case. 2. Occasionally, APH may persist for 24~48 hours. 3. Complications of APH： Hemorrhagic stroke、cerebral ischemia、encephalopathy。 myocardial ischemia、myocardial infarction、cardiac arrhythmia、congestive heart failure。 Bleeding at the surgical site Am J Health-Syst Pharm, 2004, Vol 61, 1661~1675 Frequency of APH by Surgical Procedure Procedure Frequency of APH(%) Carotid endarteretomy 9~64 Cardiac Surgery 22~54 Abdominal aortic surgery 33~75 Radical neck dissection 10~20 Intracrainal neurosurgery 57~91 Elective general surgery 3~9 Elective surgery (noncardiac) 20 Release of flexion contractures 46 Am J Health-Syst Pharm, 2004, Vol 61, 1661~1675 Guideline for the management of spontaneous intracranial hemorrhage 1. 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. 2. Advancing age and hypertension are the most important risk factor for ICH. 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 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 Stroke, 1999, 30：905~915 Blood Pressure Management 1. In general, recommendations for treatment of elevated blood pressure in patients with ICH are more aggressive than those for patients with ischemic stroke. 2. Lowering blood pressure is to decrease the risk of ongoing bleeding from ruptured small arteries and arterioles. 3. Conversely, overaggressive treatment of blood pressure may decrease cerebral perfusion pressure and theoretically worsen brain injury, particularly in the setting of increased intracranial pressure. 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 Stroke, 1999, 30：905~915 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) 35 30 25 20 35 33 15 postoperative recurrence 10 5 0 3 control MBP<110 without control MBP<110 Therapeutic Approach to Vasospasm in Subarachnoid Hemorrhage Rupture of a cerebral aneurysm ＞50% Delayed vasospasm 1/3 Symptomatic ischemia ＞20% Permanent deficits or death Current Opinion in Critical Care, 2002, 8：128~133 Treatment of Vasospasm Outcome of delayed ischemic deficits(DID) Natural history HHH treatment Nimodipine treatment Continued from prophylaxis No. patients % Dead 3327 2111 30.3 17.5 445 18 % Permanent deficit 34.0 28.5 32 De novo for DID 343 13 20 Nicardipine treatment 191 12 17 % recovery 35.7 54.0 50 67 71 HHH：Hypervolemia, Hypertension, Hemodilution Stroke, 1999, 30：905~915 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 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 基本資料 1. 一般名 : Nicardipine hydrochloride 2. 結構式 : Mechanism of Perdipine ◆ Interfere Ca2+ Influx ◆ Vasodilation ◆ Avoid Intracellular Ca2+ Accumulation ◆ Cellular Protection 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 22 patients with acute cerebral hemorrhage 24 Hour：1.140.45(range：0.61~1.69) μg/kg/min 72 Hour：0.60 0.45(range：0.24~1.06) μg/kg/min SBP(mmHg) DBP(mmHg) HR ICP(mmHg) PPC(mmHg) Before infusion 24h 72h 200 110 95 30 99 150 70 85 20 75 147 65 82 20 73 Can J Anesth, 2000, 47(12) ：1196~1201 CT Finding Hemorrhage Increase (Hematoma) No Change Decrease Edema Increase No change Decrease 24h 72h 24h after the end of in fusion 0 4 18 (82%) 0 10 12 (55%) 0 3 19 (86%) 0 8 14 (64%) 0 1 21 (95%) 0 5 17 (77%) Velocity of middle cerebral artery did not change Can J Anesth, 2000, 47(12) ：1196~1201 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 baseline Before treat After treat 161.9 61.9 277.4 80.8 212.8 65.7 Vmean(cm/.s) 105.6 43.9 201.3 65.8 145.1 54.1 PSV(cm/s) PSV：Peak Systolic velocities AJNR Am J Neuroradiol, 2004, 25：819~826 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 Perdipine Injection用法、用量 （一） Perdipine Injection 主成分：Nicardipine HCl 10mg/10ml Onset：2.5 min / 5~15 min Duration：24 min / continuous Bolus 迅速將血壓降下 建議劑量：10~30μg/kg 常用劑量：1.5~2.5 ml (slow push) 約使 BP 降低 25~30% 可再以 iv infusion 投藥持續控制血壓。 Perdipine Injection用法、用量 （二） Infusion 持續性控制血壓 （一）術中血壓控制：建議劑量 2~10μg/kg/min 常用起始劑量：(1) 原液點滴→ 8 ml/hr (microinfusion pump) (2) 5 Amp＋50ml→ 16 ml/hr (normal saline or 5%glucose) （二）高血壓急症：建議劑量 0.5~6μg/kg/min 常用起始劑量：(1) 原液點滴→ 2 ml/hr (2) 5 Amp＋50ml→ 4 ml/hr (三)文獻記載中使用於血管痙攣之劑量：2~10 mg/hr # 再依血壓監測結果調整劑量 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. Perdipine Injection Adverse Effects 總投藥病例634例 總投藥次數706次 副作用發現次數 無副作用 95.2% 心跳過速 34次 (4.8%) 25 (3.5%) 心電圖變化 5 (0.7%) 血壓低下 2 (0.3%) 體溫上升 1 (0.1%) 低血氧症 1(0.1%) (山之內製藥統計) 血壓，心搏數的變化 維持穩定血壓,不會過度降低血壓 投藥前收縮壓別效果 血壓愈高降壓效果愈顯著 0 ~159 mmHg 160~179 mmHg 20 40 60 (%) 100 80 71.0 80.8 180 mmHg ~ 87.3 顯著效果 有效 Nicardipine Increased Cerebral Blood flow 可增加腦血流量 Effects of Nicardipine in Coronary Artery Disease 有意義的增加CO&CBF 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：5~10g/kg/min，待血壓控制於 55~65mmHg 時，再 降低劑量至 1g/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。 THANKS