Catecholamine dependent systemic blood pressure in Subarachnoid Haemorrhage

CT angio of a patient with A2 aneurysm. Patient has been operated about 1 month back. Although patient is comscious and oriented with no deficit pt has become dependent on dopamine for systemic blood pressure.

 My experience is based on my observation in more than dozen patients who underwent aneurysm clipping for ruptured aneurysms at circle of Willis, and who had vasospasm and were given dopamine to raise blood pressure.. Rarely unruptured aneurysms are also operated based on indicatios like more than 5mm size or some presenting as mass effect, but surgery in unruptured aneurysms is simple and straight forward.

Depending on amount of subarachnoid haemorrhage vasospasm is frequently seen in large number of patients.  Very few patients report within 72 hours of rupture. CT angio of brain can reveal vasospasm and diffusion weighted MR images can reveal early infarcts. Not every patient undergoes  preop MRI. Majority of patients are diagnosed with CT angio. MR angiography is used in few patients who have impaired renal functions or allergy to contrast.

In a centre where 50 to 60 aneurysms are operated per year, triple HHH therapy has been used very frequently, but since last month author has stopped using Dopamine, Nor-adrenaline or adrenaline because the catecholamines have made patients dependent on them to maintain systemic blood pressure for as long as one month after surgery.  If dopamine is given for more than 5 days, patient goes into hypotension if it is stopped suddenly and atleast 2 patients had delayed ischaemic deficit because of withdrawl of dopamine. Therefore very gradual reduction of dopamine over a period of 1 week or more is advised. Tachycardia and vasospasm are also effects catecholamines. There is loss of cerebral autoregulation in severe subarachnoid haemorrhage.

Hypervolumia is a better method to sustain systemic blood pressure. I have read literature thoroughly but did not find reports of dopamine dependent systemic blood pressure in vasospasm because of  subarachnoid haemorrhage.

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