Triple H therapy

HHH is one of many ideas people have regarding neurological management. The real take home point to all of the various protocols and guidelines should be to prevent secondary injury. We can do this in many ways: decrease ICP, optimize CPP, optimize oxygenation and nutrition, and prevent vasospasm among other concepts.

Rather than create hypertension, the idea is to be very careful about aggressive treatment of hypertension. Remember: CPP= MAP-ICP. So, with elevated ICP, you can see how CPP will be decreased. This is further exacerbated by having a low MAP. A single episode of hypotension with a head injured patient can significantly decrease their chances of a meaningful recovery. So, this is why we want to be very careful about aggressive treatment of hypertension. In fact, we may want to keep it a bit on the high side in order to optimize CPP. However, we walk a thin line. Too high and we risk bleeding, vasospasm, and cardiovascular problems. Too low and we risk cerebral perfusion.

Many guidelines and protocols exist; however, the best provider will treat every patient as an individual and provide customized care. I am not a fan of telling people treat every patient with HHH or some other protocol/guideline. Rather, learn about the different theories and therapies and be ready to have a dynamic treatment plan for your patient.

Where I work we will at times keep MAPs as high as 110, assuming the aneurysm is well secured. The stroke that you're trying to prevent is an ischemic stroke due to the vasospasm clamping down the arteries. So you're willing to risk a high blood pressure for a short period to prevent that.

Think of it this way: if you're trying to push more liquid (blood) through a tube (a cerebral artery) there are three things that you can do.

You can load up the tube with more liquid - that's hypervolemia.

You can make the liquid less viscous so it slides through more easily - that's hemodilution.

And finally, you can push harder - that's hypertension.

All three have their risks. Hypervolemia risks wet lungs - up to and including pulmonary edema. Hemodilution risks depriving tissue of oxygen, if the H/H is low enough. And you're right, hypertension risks hemorrhagic stroke. It's always a trade-off on the risk/reward graph.

I took care of a triple H patient last night. The parameters we were trying to achieve were a Wedge pressure of 14-16 and SBP of 180-190. To do this we were using fluid and vasopressors. A patient who has suffered a SAH is going to spasm, you want to prevent the ischemic injury that results from the spasm. Gila RN and fins are correct...it is all about treating and preventing a secondary injury. One way to do that is by keeping the vessels open with fluid and pressure.

Theses patients can be difficult to manage both professionally and emotionally. Whenever I have a patient I am having trouble managing I remember a patient who came in with a SAH; she was in her 30's, was in pentobarb three times and we didn't think she was going to make it. She is home taking care of her three kids today...it can happen!

Well, I don't know anything about the neuro 3H stuff. But we used to give 3H enemas for constipation. High and hot and a hell of a lot.

(Actually, it wasn't hot. It was comfortably warm. And, of course, it was doctor-ordered as to quantity, etc. All the usual enema precautions applied. Do not try this without an order and good nursing judgment, of course.)

Hey... that was FANTASTIC... the explanations! I got it!! :yeah:You are wonderful folks and I know I can always count on you for extra help!! :[anb]: :clphnds:

:rcgtku: Have a GREAT day!

Well, I don't know anything about the neuro 3H stuff. But we used to give 3H enemas for constipation. High and hot and a hell of a lot.

(Actually, it wasn't hot. It was comfortably warm. And, of course, it was doctor-ordered as to quantity, etc. All the usual enema precautions applied. Do not try this without an order and good nursing judgment, of course.)

That was the first thing that came to my mind too! Good old 3H enemas.

We don't seem to do those anymore - but they always worked!