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Anticoagulant-induced subdural hemorrhage in a patient with Guillain-Barré syndrome: An anesthetic challenge

2018; Medknow; Volume: 34; Issue: 2 Linguagem: Inglês

10.4103/0970-9185.173385

2231-2730

Vivek Rayadurg, VenkatapuraJ Ramesh,

Hereditary Neurological Disorders

Madam, Guillain-Barré syndrome (GBS) is characterized by acute, progressive motor weakness, areflexia, and ascending paralysis.[1] Literature describing the perioperative anesthetic management and associated complications in these patients is lacking. We report the successful anesthetic management of a GBS patient with anticoagulant induced posterior-fossa subdural hemorrhage (SDH). A 54-year-old, approximately 70 kg male presented with headache, drowsiness, and vomiting. He was diagnosed with GBS 3 months ago; was bed-ridden since then and was on warfarin 3 mg/day for deep venous thrombosis prophylaxis. There was no history of respiratory compromise requiring respiratory support. He was hemodynamically stable; Glasgow Coma Score (GCS) was 15/15; power was grade 1/5 in all the limbs. Investigations revealed hemoglobin of 8.6 g/dL and INR 3.84. Computed tomography of the brain revealed acute posterior-fossa SDH [Figure 1] with hydrocephalus [Figure 2]. Chest X-ray showed left ventricular hypertrophy and patchy opacities [Figure 3].Figure 1: Non-contrast computed tomography brain showing posterior fossa subdural hemorrhageFigure 2: Non-contrast computed tomography brain showing hydrocephalusFigure 3: Chest X-ray AP viewWarfarin was stopped and vitamin K 10 mg administered intravenously (i.v). Transfusion of six units of fresh frozen plasma (FFP) was planned, but due to minor transfusion reactions (itching and erythematous rashes) during transfusion of the fourth unit, transfusion was discontinued. Pheniramine 22.75 mg, and Dexamethasone 8 mg administered. Repeat INR was 1.41. Patient was taken up for emergency posterior fossa craniotomy and evacuation of SDH in the prone position plus insertion of ventriculoperitoneal shunt in the supine position. Anesthesia was induced with fentanyl 150 μg and propofol 150 mg. Lignocaine 100 mg was given i.v. to suppress the response to laryngoscopy. After spraying vocal cords with lignocaine, without neuromuscular blockade, trachea was intubated with flexometallic cuffed endotracheal tube. Monitoring included an electrocardiogram, SpO2, ET CO2, invasive blood pressure (BP), respiratory gas analysis, temperature, and urine output. Anesthesia was maintained with oxygen, air, sevoflurane, and intermittent fentanyl. Neuromuscular blocking agents (NMBAs) were not administered. Significant hypotension occurred thrice — after induction, after prone positioning, and once intraoperatively — which responded to mephentermine boluses. Total blood loss of 500 ml was replaced with two units packed red cells and two units FFP. At the end of surgery, once the patient was awake and breathing spontaneously, he was extubated. GCS in the post anesthesia care unit was 15/15. Therapies available for emergency reversal of warfarin are FFP, recombinant factor VIIa (rFVIIa), and prothrombin complex concentrates (PCCs) administered with vitamin K. Although the recommendation is to treat with a mixture of PCCs and rFVIIa,[2] in view of their inavailability on the emergent basis, FFP transfusion, and i.v. vitamin K administration was advocated and found effective. Perioperative events such as laryngoscopy and intubation, blood loss, positive pressure ventilation, and positional changes may cause wide fluctuations in BP, exacerbated due to autonomic dysfunction, emphasizing the need for invasive BP monitoring. Succinylcholine is contraindicated in GBS, due to the risk of potentially fatal hyperkalemia.[3] Nondepolarizing NMBAs may result in prolonged neuromuscular block and postoperative mechanical or assisted ventilation may be required.[4] In view of the possibility of prolonged neuromuscular blockade and the need for immediate postoperative neurological assessment, NMBAs were completely avoided. However, wherever possible neuromuscular monitor is indicated. Although GBS patients should be investigated for pulmonary dysfunction because of the risk of asymptomatic impaired lung function,[5] assessment could not be done due to the emergent nature of the surgery. Because there was no history of respiratory distress or previous ventilatory support, and because we avoided NMBAs, we could safely extubate the patient.