Monitoring intravascular volumes to direct hypertensive, hypervolemic therapy in a patient with vasospasm

The common therapeutic approach to patients, who develop vasospasm following subarachnoid hemorrhage, is usually composed of hypertension, hypervolemia, and hemodilution (HHH). This therapy often leads to cardiopulmonary complications, including significant heart failure and pulmonary edema. We describe a 40-year-old woman who developed vasospasm 8 days after surgery for clipping an aneurysm, following a large subarachnoid hemorrhage. The patient required HHH therapy with a very high blood pressure to optimize her clinical neurologic status, but she started to develop pulmonary edema resulting from this therapy. This manifested as a need for increasing oxygen to maintain a normal arterial saturation. To avoid further hemodynamic compromise, we used a new monitor of cardiac function to measure intravascular volumes and quantify pulmonary edema to help titrate the fluid management of a patient in severe vasospasm. We conclude that monitoring volumes with the PiCCO cardiac monitor can help make clinical decisions in patients requiring HHH. This enables maintaining a hypertensive and hypervolemic state while avoiding cardiopulmonary complications such as heart failure and pulmonary edema. It may also help prevent the need for mechanical ventilation in these situations.