HEMORRAGIA SUBARACNOIDEA

MIGRAA
J. Urquiza Z. M.C. F.C.
MANEJO INICIAL

Airway and oxygenation

Intubation and mechanical ventilation may be indicated for patients with
decreased mental status, compromised airways, or acute lung injuries from
subarachnoid hemorrhage: neurogenic pulmonary edema, aspiration, or a
Glasgow Coma Scale motor score 7.

Blood Pressure
The exact relationship between aneurysmal rebleed and BP remains to be
identified; however, most clinicians agree that to prevent rebleed, BP control
is achieved before aneurysm securement. Systolic BP is kept between 100
and 140 mm Hg before aneurysm securement.

Intravenous fluids and Nutrition.

The goal is to maintain euvolemia (central venous pressure [CVP] 58 mm
Hg) in the patient recovering from aSAH. Normal saline may be infused at
rates between 80 and 100 cc/hr (23 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 the
patient is not preoperative, stuporous, or comatose, advancing the diet as
tolerated is ideal.
 TRATAMIENTO

Cerebral edema treatment

In patients with cerebral edema, 2% or 3% hypertonic saline may be ad-
ministered at a rate of 75150 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 145155 meq/L and serum osmolarity 300320 mOsm/L levels.

Calcium channel blockers

Nimodipine, 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 bloodbrain 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.
 NIMODIPINO
EFICACIA
Farmacodinamia: Canales tipo L. Selectividad cerebral.
Farmacocintica: F: 100%. 1er Paso. Lipoflico. MH:.
ER:50% inalterado.
E. Comparativa: > Dihidropiridinas en HSA.

SEGURIDAD
RAM: Hipotensin. Digestivas. Somnolencia-excitacin.
Interacciones: Valproato. Hipotensores. Fenitona.
Furosemida.
CI: . Hipotensin grave. ICC. I. Heptica. I Renal Severa. ( C)

C/B: Medio/Alto

DOSIS: VO: 60 mg c/4 h. Dosis Mx: 240 mg/dia. 21 das.

EV: Infusin 1 mg/hora.
TRATAMIENTO
Seizure prophylaxis
Seizure prophylaxis is maintained during the entire preaneurysm securement
phase because of increased risk of aneurysm rebleed associated with seizures
The alternatives are phenitoin, phosphenitoin and valproic acid.
Seizure prophylaxis should be discontinued 23 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 grades
IV, V).

Pain management
Headache pain is usually intense after aSAH. Analgesics are administered as
needed 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.

Antiemetics
Prevention and treatment of nausea and vomiting are also important for the
aSAH patient, both before and after aneurysm securement, especially during
the first 24 hours. Vomiting increases ICP and can cause aneurysmal
rebleed. Patients with nausea should receive an antiemetic as Difenhidra-
mine or Ondansetron routinely.
TRATAMIENTO
Gastrointestinal hemorrhage prophylaxis
Histamine-receptor antagonists or proton pump inhibitors are instituted to
prevent ulcer formation and gastrointestinal hemorrhage.

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

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

Stool softeners
Stool softeners are initiated. The patient with an unsecured aneurysm should
not strain to have a bowel movement, and stool softeners maintain soft stool
Lactulose is preferred to diphenilmetano derivates.
CRITERIOS DIAGNOSTICOS DE MIGRAA
 RIESGOS CVS DE AINES
En comparacin con el uso de ningn AINE, los cocientes
de riesgo (95% intervalos de confianza) para muerte/IMA
fueron:
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 observ para los inhibidores COX-2 selectivos y para
diclofenaco. 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
NAPROXENO
EFICACIA
Farmacodinamia: Indice COX2/COX1: 1
Farmacocintica: I: 1 h Max: 1-4 h D: 7 h. F: 99% alim
E. Comparativa: > AAS. Equivalente: Deriv. Ac. propinico.

SEGURIDAD
RAM: Digestivas. Drmicas. Cefalea. Renales.
Interacciones: Paracetamol. Glucocorticoides. Hipotensores.
CI: Anafilaxia AINES. Ulcera pptica. 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)
KETOROLACO
EFICACIA
Farmacodinamia: Elevada afinidad COX. Antinociceptor central.
Farmacocintica: I: 30vo/10im/1ev. D: 6 h. F: 100%. ER: 92%
E. Comparativa: > Aines, DHT. Triptanes. 30 mg=9 mg morfina

SEGURIDAD
RAM: Digestivas. Drmicas. Renales. Hemticas.
Interacciones: Paracetamol. Glucocorticoides. Hipotensores.
CI: Anafilaxia AINES. Ulcera pptica. I Renal Severa. ( C)

C/B: Medio/Alto

DOSIS: VO: 30 - 40 mg/da c/6-8 h. Dosis Mx: 40 mg/dia.

VIM: 30 60 mg/dosis. Dosis Mx: 150 mg/da.
VEV: Infusin continua en no menos de 8 min.
RECEPTORES SEROTONINRGICOS 5HT1 ( AMPc)
ERGOTAMINA TARTRATO
EFICACIA
Farmacodinamia: Agonista/antagonista: alfa, 5HT-1,2 y D-1,2
Farmacocintica: I: 30 a 3 h. Max: 1-2 h. D: 24 h. F:<5% Met
E. Comparativa: > AAS. < Triptanes.

SEGURIDAD
RAM: Cardiovasculares: Vasoespasmo. Neurolgicas: Cefalea.
Interacciones: Triptanes. Betabloqueadores. Macrlidos.
CI: HTA grave. Vasculopata Perifrica/Coronaria. IRenal. (X)

C/B: Bajo/Medio-alto

DOSIS: VO: 1- 2 mg al inicio + 1 mg c/30. Mximo: 6 mg/24 h

Nios >6 a: VO: 1 mg + 1 mg c/h. Mximo: 3 mg/24 h
SUMATRIPTAN
EFICACIA
Farmacodinamia: Agonista 5HT-1B 5HT1-D: (-) ACiclasa
Farmacocintica: I: 10sc/30vo. Max: 12-2 h D: 2 h. F: 18%
E. Comparativa: > Ergotamina. AINES. < Rizatriptan

SEGURIDAD
RAM: Cardiovasculares: Angina. Neurolgicas: Sedacin.
Interacciones: Antidepresivos TC. Ergotamina y DHE (24 horas).
CI: Cardiopata Isqumica. HTA no controlada. IR. IH. (C).

C/B: Alto/Alto

DOSIS:
VO: Inicio: 25-100 mg. Luego c/2h: 25-100 mg. D. Mx: 300 mg/d
SC: Inicio: 6 mg. Si es necesario a la hora: 6 mg. D. Mx: 12 mg/d
CODEINA
EFICACIA
Farmacodinamia: Agonista mu. + supraespinal.
Farmacocintica: I: 10 im. D: 4 h. UPP: 7%. MH: Morfina. ER:
E. Comparativa: > Aines, DHT y Triptanes. 120 mg=10 mg morfina

SEGURIDAD
RAM: Somnolencia. Constipacin. Respiratoria. Cefalea. Nasea.
Interacciones: Metoclopramida. Loperamida. Furazolidona. OH.
CI: I Respiratoria. Diarrea toxignica. I Renal Severa. (C)

C/B: Bajo/Alto

DOSIS: VIM: 15 60 mg/dosis/4 h. Dosis Mx: 240 mg/da.

Nios >s 2 a: 0,5 mg/kg/6 h
FARMACOS PREVENTIVOS EN MIGRAA CRONICA