Thursday August 3, 2006
3 Cs of Intensivist !


Q; What makes a 'successful' Intensivist ?

A; 3 Cs

• Communicative
• Co-operative
• Cost-effective

Wednesday August 2, 2006
In hypertensive intracerebral hemorrhage (ICH) !

Stroke Council of the American Heart Association recommends that goal of mean arterial pressure (MAP) in patients with ICH is at less than 130 mm Hg, and if ICP monitor is in place, to maintain cerebral perfusion pressure (CPP) of more than 70 mm Hg, to reduce hematoma expansion 1.

- CVP should be maintained between 5-12 mm Hg or pulmonary wedge pressure at 10-14 mm Hg.
- If systolic arterial blood pressure falls below 90 mm Hg, pressors should be given.

Last year Dr. Adnan Qureshi and coll. from UMDNJ - University of Medicine and Dentistry of New Jersey, Newark, NJ, reported that patients treated within 6 hours * of symptom onset were more likely to be functionally independent at 1 month compared with patients who were treated between 6 and 24 hours 2. On followup to this, last month, Dr. Qureshi and coll. reported study of 46 patients (29 patients were treated), - with intravenous nicardipine 3.The onset of intravenous nicardipine is within 1 to 5 mins and the effect last from 10 to 15 mins.

• Intravenous nicardipine was initiated at a rate of 5 mg/hr.
• If the MAP was not reduced to less than 130 mm Hg after 15 mins, the infusion dose was increased by 2.5 mg/hr.
• The 2.5-mg/hr increments continued every 15 mins until the maximum dose of 15 mg/hr was reached.
• Once the target blood pressure was reached, the infusion rate was decreased to 3 mg/hr and subsequently adjusted by 1 to 2.5 mg/hr to maintain the MAP in the targeted range (between 100 and 130 mm Hg).
• The patients with previous meds that have hypotensive properties were continued on the preadmission dose such as beta-blockers.
• Intravenous nicardipine was discontinued in the event of serious adverse event.

They looked into tolerability, neurologic deterioration, hematoma expansion and 30-days functional outcome. Group found that MAP goals recommended by the American Heart Association using intravenous nicardipine are well tolerated in patients with ICH. Also, they did not find any evidence to suggest that patients with ICH who received intravenous nicardipine within 24 hrs of symptom onset had excessively high rates of neurologic deterioration or hematoma expansion.



* A multiple-center clinical trial, Antihypertensive Treatment of Acute Cerebral Hemorrhage is underway to study this approach within 6 hrs of symptom onset 4.



References: click to get abstract/article

1. Guidelines for the management of spontaneous intracerebral hemorrhage: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1999; 30:905-915

2. A Prospective Multicenter Study to Evaluate the Feasibility and Safety of Aggressive Antihypertensive Treatment in Patients With Acute Intracerebral Hemorrhage - Journal of Intensive Care Medicine, Vol. 20, No. 1, 34-42 (2005)

3. Treatment of acute hypertension in patients with intracerebral hemorrhage using American Heart Association guidelines - Critical Care Medicine. 34(7):1975-1980, July 2006.

4. Antihypertensive Treatment in Acute Cerebral Hemorrhage trial