Hemodynamic targets are set to optimize cerebral blood flow and oxygen delivery using either data from the literature or bedside multimodality monitoring (cerebral perfusion pressure, jugular oximetry (SjO2), or transcranial Doppler flow measurements) as indices of adequate cerebral perfusion in individual patients.
Thus target levels of mean arterial pressure and cardiac index vary between disease states and individual patients, but their attainment follows generally accepted critical care practice and fluid loading with colloids is used as a first step. In the past this was titrated to central venous pressure. However, myocardial dysfunction may occur even in young neurosurgical patients as a consequence of myocardial contusion in trauma or subendocardial ischemia in subarachnoid hemorrhage, and many of these patients have significant acute lung injury. Therefore right-sided filling pressures may not provide an accurate index of volume status, and nimodipine (which is routinely used in subarachnoid hemorrhage) results in unpredictable hemodynamic consequences. These considerations have prompted the increasing use of pulmonary artery catheters for the measurement of pulmonary capillary wedge pressure, cardiac index, and systemic vascular resistance.
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