Cardiac performance enhancement from dobutamine in patients refractory to hypervolemic therapy for cerebral vasospasm

Abstract

The use of the beta-agonist dobutamine in combination with hypervolemic preload enhancement of cardiac performance was analyzed in 23 patients who failed to respond to traditional preload enhancement following aneurysmal subarachnoid hemorrhage. The patients ranged in age from 13 to 82 years, and three had a history of cardiac disease. Each patient underwent placement of a flow-directed balloon-tipped catheter and the following measurements were obtained during hyperdynamic therapy: pulmonary artery wedge pressure, central venous pressure, cardiac index, stroke volume index, total peripheral resistance, and left ventricular stroke work index (LVSWI). Mean baseline cardiac function was found to be within normal limits (LVSWI = 47.6 +/- 4.2 gm/min/sq m and cardiac index = 3.30 +/- 0.22 liter/min/sq m). After baseline measurements were recorded, 5% albumin was infused at 300 cc/hr and dobutamine was initiated at a rate of 5 to 10 micrograms/kg/hr. This hyperdynamic therapy with dobutamine in the presence of volume loading resulted in a 52% increase in cardiac index, a 15% increase in LVSWI, and a 21% decrease in total peripheral resistance. The clinical reversal of ischemic symptoms due to subarachnoid hemorrhage was evident in 18 (78%) of the 23 patients.

Milrinone for the Treatment of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage

“…22 The potential role of increased cardiac output in improving cerebral tissue perfusion independently of mean arterial pressure has been suggested by several authors. 23,24 The first and unique clinical study using intraarterial milrinone showed angiographic effectiveness to reverse CVS in patients with aSAH. 16 In this study, intraarterial milrinone was also followed by an intravenous infusion for up to 2 weeks after initial bleeding.…”

A comparison of propofol and sevoflurane anaesthesia: effects on aortic blood flow velocity and middle cerebral artery blood flow velocity*

“…Measurements of cardiac output and CBFv suggest that dobutamine increases cardiac index, CBF and CBFv in patients [17,18] indicating that changes in CBFv may be the result of changes in SBF. It has not been investigated whether reported changes in CBFv during propofol anaesthesia correlate with changes in SBFv.…”

“…The effects of sevoflurane and propofol anaesthesia on CBFv and the cardiovascular system are well documented [6][7][8][9][10][11][12][13][14]. The relationship between cardiac output and CBF is controversial [15][16][17]. Positive inotropic drugs increase cardiac output, CBF and CBFv, respectively [17,18].…”

“…The relationship between cardiac output and CBF is controversial [15][16][17]. Positive inotropic drugs increase cardiac output, CBF and CBFv, respectively [17,18]. These reports suggest that changes in systemic blood flow velocity (SBFv) may influence CBFv.…”

Treatment Options for Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage

“…These effects appear to be independent of volume status. Several case series suggest that inotropic agents improve CBF and reverse neurological deficits in patients who do not respond to vasopressors [54,55]. There is scant data to guide choice of vasopressor or inotropic agent and the choice must be made based on empiricism and theoretical advantages that are based on pharmacology and individual patient physiology.…”