J. Urquiza Z. M.C. F.C.

Airway and oxygenationIntubation and mechanical ventilation may be indicated for patients withdecreased mental status, compromised airways, or acute lung injuries fromsubarachnoid hemorrhage: neurogenic pulmonary edema, aspiration, or aGlasgow Coma Scale motor score ≤ 7.

Blood PressureThe exact relationship between aneurysmal rebleed and BP remains to beidentified; however, most clinicians agree that to prevent rebleed, BP controlis achieved before aneurysm securement. Systolic BP is kept between 100and 140 mm Hg before aneurysm securement.

Intravenous fluids and Nutrition.The goal is to maintain euvolemia (central venous pressure [CVP] 5–8 mmHg) in the patient recovering from aSAH. Normal saline may be infused atrates between 80 and 100 cc/hr (2–3 L of 0.9% NaCl per 24 hours.Parenteral nutrition via continuous infusion is started on day 2 after hemo- rrhage if the patient is unable to eat or tolerate enteral feedings. If thepatient is not preoperative, stuporous, or comatose, advancing the diet astolerated is ideal.

Cerebral edema treatmentIn patients with cerebral edema, 2% or 3% hypertonic saline may be ad-ministered at a rate of 75–150 cc/hr unless contraindicated. Frequent electrolyte monitoring is indicated at least every 6 hours. Monitor and replace potassium to maintain normal levels. Monitor serum sodium to a goal of 145–155 meq/L and serum osmolarity 300–320 mOsm/L levels.

Calcium channel blockersNimodipine, a calcium channel blocker, is the only drug currently approved by the FDA for the prevention and treatment of vasospasm following aSAH.Nimodipine crosses the blood–brain barrier and inhibits calcium entry into cells, subsequently reducing the contractile state of the vascular smooth muscle. Oral or enteral administration of 60 mg of nimodipine c/4 hours is instituted within 96 hours after hemorrhage and continued for up to 21days.

EFICACIAFarmacodinamia: Canales tipo L. Selectividad cerebral.Farmacocinética: F: 100%. ↑1er Paso. Lipofílico. MH:↑. ER:50% inalterado.E. Comparativa: > Dihidropiridinas en HSA.SEGURIDADRAM: Hipotensión. Digestivas. Somnolencia-excitación. Interacciones: Valproato. Hipotensores. Fenitoína. Furosemida. CI: . Hipotensión grave. ICC. I. Hepática. I Renal Severa. ( C)C/B: Medio/AltoDOSIS: VO: 60 mg c/4 h. Dosis Máx: 240 mg/dia. 21 días. EV: Infusión 1 mg/hora.

Seizure prophylaxisSeizure prophylaxis is maintained during the entire preaneurysm securementphase because of increased risk of aneurysm rebleed associated with

seizuresThe alternatives are phenitoin, phosphenitoin and valproic acid.Seizure prophylaxis should be discontinued 2–3 days after aneurysm secure-ment unless the patient has seized or is unstable. In higher-grade patients,anticonvulsants may be continued until ICU discharge (Hunt and Hess gradesIV, V).

Pain managementHeadache pain is usually intense after aSAH. Analgesics are administered asneeded for pain. Pain causes increased BP, heart rate, and anxiety. All of these can increase risk for aneurysmal rebleed and, therefore, must be treated immediately. Opioids can be necessary in severe pain.

AntiemeticsPrevention and treatment of nausea and vomiting are also important for theaSAH patient, both before and after aneurysm securement, especially duringthe first 24 hours. Vomiting increases ICP and can cause aneurysmalrebleed. Patients with nausea should receive an antiemetic as Difenhidra-mine or Ondansetron routinely.

Gastrointestinal hemorrhage prophylaxisHistamine-receptor antagonists or proton pump inhibitors are instituted toprevent ulcer formation and gastrointestinal hemorrhage.

IV fluidsIV fluids are maintained to assure adequate hydration. In patients withsymptomatic vasospasm, triple H therapy (hypervolemia, hypertension,And hemodilution) remains a frequently used regimen in the prevention of cerebral vasospasm after aSAH.

DVT prophylaxisThigh-high stockings and pneumatic (sequential) compression devices aremaintained postaneurysm securement. When the aneurysm has been secu-red, heparin therapy for prevention of DVT may be considered.

Stool softenersStool softeners are initiated. The patient with an unsecured aneurysm shouldnot strain to have a bowel movement, and stool softeners maintain soft stoolLactulose is preferred to diphenilmetano derivates.

CRITERIOS DIAGNOSTICOS DE MIGRAÑA

En comparación con el uso de ningún AINE, los cocientesde riesgo (95% intervalos de confianza) para muerte/IMAfueron:1,01 (0,96-1,07) para el ibuprofeno,1.63 (1.52-1,76) para el diclofenaco, 0,97 (0,83-1,12) para el naproxeno, 2,13 (1,89-2,41) para rofecoxib, 2,01 (1,78-2,27) para celecoxib. Un aumento dependiente de la dosis en el riesgo cardiovas-cular se observó para los inhibidores COX-2 selectivos y paradiclofenaco. El uso de AINES en general debe ser cauteloso y las dosis especialmente altas deben evitarse si es posible.

Clinical pharmaco logy & Therap eutics | 85 : 2 | FEB 2009 191

EFICACIAFarmacodinamia: Indice COX2/COX1: 1Farmacocinética: I: 1 h Max: 1-4 h D: 7 h. F: 99% ↓ alimE. Comparativa: > AAS. Equivalente: Deriv. Ac. propiónico.

SEGURIDADRAM: Digestivas. Dérmicas. Cefalea. Renales. Interacciones: Paracetamol. Glucocorticoides. Hipotensores.

CI: Anafilaxia AINES. Ulcera péptica. I Renal Severa. ( B - D)

C/B: Bajo/Alto

DOSIS: VO: 500 (550) a 1,1 g/dia c/8-12 h. VO: 10 mg/kg c/12 h. (3-12 a: 125 mg c/8 h)

EFICACIAFarmacodinamia: Elevada afinidad COX. Antinociceptor central.Farmacocinética: I: 30’vo/10’im/1’ev. D: 6 h. F: 100%. ER: 92%E. Comparativa: > Aines, DHT. ≥ Triptanes. 30 mg=9 mg

morfina

SEGURIDADRAM: Digestivas. Dérmicas. Renales. Hemáticas. Interacciones: Paracetamol. Glucocorticoides. Hipotensores. CI: Anafilaxia AINES. Ulcera péptica. I Renal Severa. ( C)

C/B: Medio/Alto

DOSIS: VO: 30 - 40 mg/día c/6-8 h. Dosis Máx: 40 mg/dia. VIM: 30 – 60 mg/dosis. Dosis Máx: 150 mg/día. VEV: Infusión continua en no menos de 8 min.

RECEPTORES SEROTONINÉRGICOS 5HT1 (↓ AMPc)

EFICACIAFarmacodinamia: Agonista/antagonista: alfa, 5HT-1,2 y D-

1,2Farmacocinética: I: 30’ a 3 h. Max: 1-2 h. D: 24 h. F:<5%

↑MetE. Comparativa: > AAS. < Triptanes.

SEGURIDADRAM: Cardiovasculares: Vasoespasmo. Neurológicas: Cefalea. Interacciones: Triptanes. Betabloqueadores. Macrólidos.CI: HTA grave. Vasculopatía Periférica/Coronaria. IRenal. (X)

C/B: Bajo/Medio-alto

DOSIS: VO: 1- 2 mg al inicio + 1 mg c/30’. Máximo: 6 mg/24 h Niños >6 a: VO: 1 mg + 1 mg c/h. Máximo: 3 mg/24 h

EFICACIAFarmacodinamia: Agonista 5HT-1B 5HT1-D: (-) ACiclasaFarmacocinética: I: 10’sc/30’vo. Max: 12’-2 h D: 2 h. F: 18%E. Comparativa: > Ergotamina. ≥ AINES. < Rizatriptan

SEGURIDADRAM: Cardiovasculares: Angina. Neurológicas: Sedación.Interacciones: Antidepresivos TC. Ergotamina y DHE (24

horas). CI: Cardiopatía Isquémica. HTA no controlada. IR. IH. (C).

C/B: Alto/Alto

DOSIS: VO: Inicio: 25-100 mg. Luego c/2h: 25-100 mg. D. Máx: 300

mg/dSC: Inicio: 6 mg. Si es necesario a la hora: 6 mg. D. Máx: 12

mg/d

EFICACIAFarmacodinamia: Agonista mu. + supraespinal.Farmacocinética: I: 10’ im. D: 4 h. UPP: 7%. MH: Morfina. ER:

↑E. Comparativa: > Aines, DHT y Triptanes. 120 mg=10 mg

morfina

SEGURIDADRAM: Somnolencia. Constipación. ↓ Respiratoria. Cefalea.

Naúsea.Interacciones: Metoclopramida. Loperamida. Furazolidona.

OH. CI: I Respiratoria. Diarrea toxigénica. I Renal Severa. (C)

C/B: Bajo/Alto

DOSIS: VIM: 15 – 60 mg/dosis/4 h. Dosis Máx: 240 mg/día. Niños >s 2 a: 0,5 mg/kg/6 h