Case Week 4 (w/c 24/10/11)
This week’s case marks a return to planning of anaesthesia.
No single tweet will raise all the relevant points so we would like as many as possible to join in.
A 66 year old woman is listed for semi-urgent craniotomy and clipping of right MCA aneurysm. She had a subarachnoid haemorrhage 10 days ago, resulting in extensive L sided hemiparesis which persists. Surgery has been delayed until this point due to the request of her family as they were unsure as to whether they wanted to proceed, and because of a hospital-acquired pneumonia 5 days ago, for which she is receiving iv tazocin.
Initially this lady was treated with a labetolol infusion to lower her blood pressure (210/100). Over the last 36 hours she has been relatively unstable haemodynamically, with a labile BP. Labetolol has been off for 48hours; she has had a total of 1000ml of colloid boluses (alongside a maintainance fluid infusion). This morning BP is 130/60
Chest now better clinically. Family and patient keen to proceed.
What are your anaesthetic options?
Thank you for your comments. New information is now available.
The patient is currently being managed in a level 2 bed on neurosurgical HDU. She has an arterial line and femoral CVC in situ. An angiogram showed a complex aneurysm in the right MCA that anatomically was unsuitable for endovascular coiling. The neurosurgical team feel that she is at high risk of rebleeding, hence their intention to manage surgically.
Her bloods this morning were unremarkable aside from Hb of 10.1 (note platelet count 250 and coagulation normal).
Does this information change your plans at all?
Don’t forget to include #gasclass in your response!
In response to concerns about respiratory status-her CXR shows a resolving R basal consolidation. SpO2 is 97% on 4l via nasal spec; ABG pH 7.37 pO2 11.1, pCO2 5.1 Bi 23 BE -2
The patient has RA which is affecting all joints but particularly wrists, knees and neck. She has limited mouth opening (2.5cm) and a relatively fixed neck. There is no previous information regarding GA; she has had previous discectomy at C5/6 (but not fusion).
How does this affect your anaesthetic plan?