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Hyperdynamic or “Triple HHH” therapy is used in the management of vasospasm or suspected vasospasm. Of note "HHH" therapy can be initiated in the event of multiple aneurysms so long as the ruptured one has been clipped (reference 2).
Hypertension - Systolic Blood Pressure > 160 (max 220), use pressors if necessary, (if unclipped aneurysm, SBP should be kept less than 160). Keep at the lowest possible level to either reduce elevated TCDs, or, in the event of clinical vasospasm, to maintain neurologic function.
Hypervolemia - fluids at approximately 200cc per hour, use desmopressin if urine output greater than 200cc per hour. CVP should be 8-12 cm H2O (6-10 if unclipped aneurysm)
Hemodilution - Hematocrit between 25 and 33%
- Central and peripheral line, Foley, TCDs
- Administer O2 to keep pO2 > 70
- Serum and urine electrolytes and osmolalities at least BID
Contraindications (as HHH can exacerbate each):
- Massive edema
- Large ischemic infarct
- Elevated ICP
- Rebleeding/New Hemorrhage
- Pulmonary edema
1. Kassell N F, Peerless S J, Durward Q J et al.: Treatment of ischemic deficits from vasospasm with intravascular volume expansion and induced arterial hypertension. Neurosurgery 11: 337-43, 1982.
2. Swift D M, Solomon R A: Unruptured aneurysms and postoperative volume expansion. J Neurosurg 77: 908-10, 1992.
3. Greenberg, MS et al.: Handbook of Neurosurgery, 6th edition. New York: Thieme. 2006.