Hemodynamic manipulation

Hemodilution secondary to fluid therapy may reduce blood viscosity and improve microcirculatory characteristics. However, it may also cause a reduction in hemoglobin levels with a net decrement in tissue oxygen delivery. Thus hematocrit levels are generally maintained above 30 per cent.

If volume loading does not achieve the hemodynamic targets, vasoactive agents are administered. Most published work describes the use of dopamine, phenylephrine, or norepinephrine (noradrenaline), with the emphasis being on mean arterial pressure elevation rather than cardiac index enhancement. Cerebral perfusion pressure targets of 60 to 70 mmHg are sought. Guidance regarding cardiac index targets are not available for most conditions, but in our experience isolated cardiac index elevation with dobutamine and dopexamine have not been useful in maintaining cerebral perfusion.

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