Fig. 32.1
The MRI clearly shows a hyperdensity in the right occipital lobe. An arteriovenous malformation was the cause of the bleeding
After the MRI, the neurosurgeon Dr. Faith came to Mrs. Smith to discuss the findings and further treatment.
“Mrs. Smith,” she said, “we have located the cause of your symptoms. In the back of your head, there is a vascular malformation which began to bleed a little bit. This is both good news and bad news. The good news is that you do not have a tumor; the bad news is that you could bleed again at any time from the abnormal vessels.” Dr. Faith paused for a moment to allow the news to sink in.
With a shivering voice Mrs. Smith responded, “Am I going to die?”
“Bleeding within the brain is always life-threatening, but the most important thing is that we have found the cause of the bleed and we can now suggest treatment.”
Dr. Faith had won over Mrs. Smith’s trust. She explained the various therapeutic options and concluded with her recommendation of the least invasive method: endovascular embolization. Mrs. Smith agreed to this procedure.
“We have an excellent specialist here, an experienced neuroradiologist who will perform your procedure,” explained Dr. Faith. “However, he is on vacation at the moment and we must be patient for a week. I’ll go ahead and call the anesthesiologist for you.”
Dr. Perk was freshly board certified, and tended to get stuck with all the jobs nobody else wanted to do. Within his department, he was known for his wit and had already been written up once for being a clown in the OR.
When his phone rang, he was talking with a cute female colleague. He answered with, “Department of Anesthesiology, please hold, someone will be with you shortly,” then glanced at the display. “Uh–oh!” he thought as he read the screen: Dr. Eldridge. The attending had an unpredictable sense of humor.
“Perk,” said the anesthesiologist–in–charge, “When are you going to grow up? You’re in the big boys group now. In neurosurgery there is a patient, Mrs. Smith, who is waiting for her preoperative consult. I hope that you can rise to the challenge.”
With that, the conversation was over. “Guys,” said Dr. Perk, pulling himself up tall in front of his colleagues, “that was the big boss. I have been given a special assignment – and I gotta go double–oh–seven it. Ciao!”
32.1.2 What Does the Anesthesiologist Need to Watch Out for in This Case?
In case 30 (see Sect. 30.1.3), a neuroradiology case was discussed. The main aspects are:
Difficult patient access during the intervention
Careful monitoring of the blood pressure, especially avoiding blood pressure peaks
Continuous neuromuscular blockade in order to minimize the danger of vessel rupture during the procedure
>> After viewing the file, Dr. Perk had put together the following details:
63 years old, 165 cm, 81 kg.
A fall 10 days ago, after which there was temporary incomplete paralysis of the left arm.
EEG showed oscillations typical of epilepsy on the right side of the brain (epileptiform discharges), and treatment was begun with levetiracetam.
Angiography detected a bilateral dural arteriovenous fistula over the occipital arteries.
Other preexisting conditions:
Systemic hypertension treated with bisoprolol, amlodipine, enalapril, and furosemide
Asthma treated with salmeterol and budesonide spray
Type 2 diabetes treated with short– and long–acting insulin
Renal failure stage II
Obesity and hyperlipidemia treated with simvastatin
Aspirin paused; pantoprazole to prevent ulcers continued
32.1.3 What Is Stage II Renal Failure?
The US National Kidney Foundation divides renal insufficiency into five stages (Table 32.1).
Table 32.1
Classification of renal failure
Stage | Glomerular filtration rate [ml/min/1.73 m2] | Characteristics |
|---|---|---|
1 | >89 | Proteinuria, normal kidney function |
2 | 60–89 | Mild impairment of renal function with or without proteinuria |
3 | 30–59 | Moderate impairment of renal function |
4 | 15–19 | Severe impairment of renal function |
5 | <15 | Chronic renal failure |
Due to the necessary administration of contrast dye, Ms. Smith is at increased risk for post-interventional acute renal failure (see Sect. 29.2.4).
>> “Totally healthy patient with asthma, metabolic syndrome, and hypertension,” thought Dr. Perk, as he was making his way to the patient’s room. In the lab work–up, he noticed an elevated creatinine. But that fit in with renal failure. The ECG was unremarkable, apart from minor left ventricular hypertrophy.
During the conversation, Mrs. Smith explained that she went regularly to her family physician. Her hypertension was well controlled, and her blood sugar fluctuated very little (she dosed her insulin very carefully). She managed her asthma successfully as well. “What do you mean? How many flights of stairs can you climb?” probed Dr. Perk. “Well, after 1–2 floors, I stop to take a break,” answered Mrs. Smith, “then I inhale my spray and wait a moment until I can breathe OK again.”
32.1.4 What Do You Think of This Physical Fitness Report?
Mrs. Smith complained of dyspnea upon exertion, the cause of which couldn’t be determined from the history. It may be asthma, or it may have a cardiac cause. Useful preoperative tests therefore include:
Pulmonary function tests including reversibility testing of airflow limitation for possible optimization of the asthma therapy
Cardiac stress test/stress echo
The indication for these tests must be viewed critically, due to the intracranial bleed and the possible increase in intracranial pressure with exercise, which increases the danger of recurrent hemorrhage. Alternatively, transthoracic echocardiography can safely assess pump function, diastolic relaxation, valve abnormalities, and pulmonary arterial pressure.
Coronary artery disease, however, cannot be ruled out with this technique.
>> Dr. Perk obtained informed consent from Ms. Smith for the anesthesia. “We’ll see each other in a week!” he said as he left.
As he was sitting in his office completing the paperwork, he began to worry about whether or not to order additional tests. After short deliberation, he decided to call anesthesiologist-in-charge Dr. Eldridge for advice. After 3 rings, Dr. Eldridge answered “Department of Anesthesiology – please hold – someone will be with you shortly…” Very funny, thought Dr. Perk, and a little resentful. Anyway, he described Mrs. Smith’s medical problems. In response to Dr. Eldridge’s first question, he reported that Mrs. Smith had denied experiencing a change in her dyspnea within the past few weeks. Together, the anesthesiologists decided against additional diagnostic tests.
“Good morning, Mrs. Smith!” Dr. Perk said to her a week later. He reviewed the patient’s medical record once more, and saw to his astonishment, that thoracic CT angiography was done the very same day when he saw her for her preoperative evaluation. The reason for the test was “acutely worsening dyspnea with tachycardia.” Pulmonary emboli were ruled out.
In the meantime, CRNA Rose had gotten Mrs. Smith hooked up to the monitor:
S P O 2 92 %
Blood pressure 120/60 mmHg
HR 80 beats/min, sinus rhythm
Induction of the TIVA with remifentanil, propofol, and atracurium went without incident, as well as endotracheal intubation and placement of an arterial line. To assist in maintaining a stable blood pressure, Mrs. Smith received 1,000 ml of crystalloid and a phenylephrine infusion was started at 40 μg/min. CRNA Rose gave Dr. Perk a copy of the arterial blood gas analysis. “Thanks,” he said “but we really don’t need this.” The abnormal values were:
Na +: 130 mEq/l (reference 135–150 mEq/l)
Hb 9.2 g/dl (reference 11.9–17.2 g/dl)
Glucose 145 mg/dl (reference 70–99 mg/dl)
Unfortunately, the planned embolization of the vessel abnormality could not be performed due to substantial elongation of the artery. The attempt was aborted after 2 h. “What a shame for Mrs. Smith,” Dr. Perk said to CRNA Rose, “Now they will have to do a craniotomy.” He stopped the atracurium infusion, and 15 min later the neuroradiologist said goodbye. After another 20 min, the propofol and remifentanil infusions were stopped. Dr. Perk expected a quick awakening. After another 15 min, Mrs. Smith was still not wake–able. She had tachypnea and was breathing with a very low tidal volume.
32.1.5 What Do You Think of When You See the Presented Signs?
The answer shouldn’t be too difficult for you:
The symptoms are typical for postoperative residual neuromuscular blockade. The diagnosis is confirmed via nerve stimulation (see Sects. 12.1.4 and 16.1.9). The therapy involves either reversing the neuromuscular blockade or waiting (see Sect. 12.1.4).
>> Dr. Perk was shocked to see that the TOF showed complete muscular recovery. “Well, OK,” he thought, “I’ll give Mrs. Smith a little more time.” Twenty–five minutes later, her spontaneous breathing was sufficient enough to extubate, and the increase in heart rate and blood pressure hinted that Mrs. Smith was going to wake up soon. “Let’s extubate now” he said to his nurse. “Stress isn’t good for Mrs. Smith’s intracranial bleed.” After extubation, Mrs. Smith was hooked up to the transport monitor. Just before they started rolling, CRNA Rose glanced at the screen. “Dr. Perk – did you see the pulse and pressure?” The blood pressure was 185/75 mmHg, and the heart rate was 120 beats/min. Dr. Perk replied, “Let’s get her to the PACU – the guys there will take care of it.”
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