Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 55, Num. 2, 2007, pp. 175-176

Neurology India, Vol. 55, No. 2, April-June, 2007, pp. 175-176

Letter To Editor

Preoperative hypoxemia in a patient for elective aneurysm clipping: Which one to be managed on priority?

Haris Aziz, Nair Sujit, Dash HH, Lad SK

Department of Anesthesiology and Intensive Care and Neurosurgery, Khoula Hospital, Muscat
Correspondence Address:Department of Anesthesiology and Intensive Care and Neurosurgery, Khoula Hospital, Muscat drhh_dash@yahoo.com

Date of Acceptance: 16-Jan-2007

Code Number: ni07065

Sir,

Medical complications significantly contribute to the incidence of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH) and it may be as high as that caused by the direct effects of SAH, re-bleeding and vasospasm. Pulmonary dysfunction was responsible for 50% of all deaths.[1],[2] It is not only intriguing but also an intricate issue for both the neurosurgeons and anesthesiologists whether to treat the associated medical complications on priority or to undertake early surgery. A 40-year-old, 65 kg woman was admitted with intense and sudden bifrontal headache since two days. It was associated with transient unconsciousness and vomiting. However, her sensorium improved after hospitalization. Brain CT revealed blood in the anterior inter-hemispheric fissure. Cerebral angiography confirmed anterior communicating artery aneurysm for which, she was posted for surgery. Preanesthetic evaluation revealed Hunt and Hess Grade II patient. Her heart rate was 44/min and regular. Blood pressure was 140/78 mmHg. Other systemic examinations were noncontributory. She was premedicated with midazolam (5 mg IM). On the morning of the operation as her SaO ₂ was low (85 to 92%), an arterial blood gas was done which showed hypoxemia [Table - 1]. She was administered O ₂ by mask and transferred to operation theatre. Clinical evaluation revealed respiratory rate was 22/min with decreased air entry and crepitations on both bases. Her pulse rate was 44/ min, regular and BP - 130/80 mmHg. Repeat blood gas showed PaO ₂ of 45.8 mmHg [Table - 1]. Chest X-ray showed right interlobar effusion with patchy atelectasis at left lower base [Figure - 1]. The neurosurgeon was informed but he was for early surgery so as to prevent re-bleeding. Balanced anesthetic technique was used (propofol-120 mg, lignocaine-100 mg, atracurium-40 mg, OTC (7.5), O ₂ : N ₂ O (1:1), fentanyl, isoflurane and IPPV). Continuous monitoring of vital parameters including CVP, IBP was continued. Mannitol 300 ml was used. The operation lasted for 215 minutes. She received 3.5L fluids (NS- 2000 ml and Ringer's lactate 1500 ml) intraoperatively. Urine output was 1300 ml. As she was desaturating following reversal, she was transferred to ICU for ventilation. She was ventilated with a FiO ₂ - 0.5 and PEEP of 10 mmHg. Postoperative chest X-ray showed right lower lobe pneumonia and patchy atelectasis [Figure - 2] on the left side which resolved gradually [Figure - 3] along with improvement of arterial blood gases [Table - 1] by the seventh postoperative day. She was put on weaning mode and was extubated the next day. She was discharged on the 15th postoperative day with good neurological state. It is imperative for both anesthesiologist and surgeon to find out the cause of hypoxemia and institute aggressive treatment. Our patient, obviously had signs of Type II respiratory failure[3] on the day of surgery. Retrospectively, one can postulate that she probably had aspirated during the ictus following unconsciousness. That had provided the nidus, which got manifested on the day of surgery as hypoxemia following basal pneumonia [Figure - 1].

In the era of evidence-based medicine, when the proportion of deaths from medical complications has rivaled each of the neurological complications,[4] obviously, the question is, to what extent is it logical and medico-legally appropriate to accept a patient with cardio-respiratory complications for early surgery. The problem of re-bleeding during management of respiratory problem was a major medico-legal dilemma in our patient. Therapeutic options are available in the postoperative period to treat basal pneumonia. All these facts provided the impetus to accept the challenge. We feel that if there is provision of ICU facilities then surgery for intracranial aneurysm must be given priority over cardio-respiratory complications in patients with SAH Grade II so as to prevent the dreaded complication, that is, re-hemorrhage.

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Copyright 2007 - Neurology India

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