Poor-grade subarachnoid haemorrhage for coiling54-year-old woman, 68 kg, with aneurysmal subarachnoid haemorrhage 10 hours ago

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 54-year-old with poor-grade SAH, unsecured aneurysm and a drain, for urgent coiling in a remote suite. Patient
   • WFNS IV makes her high-grade; her prognosis has been discussed with her family. Disease
   • Rebleeding before the coil goes in carries high mortality.
   • Her stunned myocardium, EF 40%, leaves little room for swings in pressure.
   • Remote suite: unfamiliar, few hands, and poor access once the C-arm is in. Surgery

2. Prepare

   How will you prepare her?

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   • Arterial line before induction; her pressure needs beat-to-beat control. Disease
   • EVD clamped for transfer; zeroed at the ear when it's open.
   • No sudden CSF drainage: it changes the pressure across the aneurysm wall.
   • ECG checked: a long QT is common after SAH.
   • Her sodium of 133 matters: salt wasting and SIADH both occur; mineralocorticoid if she's losing salt.
   • Heparin plan confirmed with the neuroradiologist, and protamine drawn up. Crisis

3. Plan

   How will you induce and run the case?

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   • Smooth induction with the laryngoscopy response firmly blunted. Airway
   • Lidocaine 1–1.5 mg/kg before laryngoscopy and a remifentanil infusion; esmolol 10–25 mg ready.
   • Systolic under 160, but MAP never under 65. Disease
   • Euvolaemia and a normal sodium; no prophylactic hypervolaemia.
   • Nimodipine 60 mg every 4 hours continues by tube. After surgery
   • Rupture plan: protamine 1 mg per 100 units of heparin, BP down, keep coiling. Crisis
   • ICU afterwards; raise BP only for symptomatic vasospasm. After surgery

4. Crisis

   At laryngoscopy, BP rises to 210/120, HR 120, and ICP to 35 mmHg. What do you do?

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   • Hypertensive surge with an unsecured aneurysm: deepen anaesthesia at once. Crisis
   • Esmolol 10–25 mg or nitroprusside 5–25 mcg IV; clevidipine 100–250 mcg is another choice.
   • Her drain can let off a little CSF to control ICP, not a large volume.
   • ICP jumping to 35 with this surge: I assume re-rupture until the first angiogram rules it out.
   • Tell the neuroradiologist now, before the catheter goes up. After surgery

5. Crisis

   After coiling, SpO2 is 85% on FiO2 0.8, with pink froth in the tube; BP 88/50, HR 112; echo shows a poorly contracting LV. What do you do?

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   • Pulmonary oedema with low output from neurogenic stunned myocardium. Crisis
   • 100% oxygen and PEEP; when she's adequately filled, PEEP needn't raise her ICP.
   • Noradrenaline 0.05–0.3 mcg/kg/min to restore her cerebral perfusion.
   • Still low output despite pressure: dobutamine from 2.5 mcg/kg/min, titrated to output.
   • No fluid loading; hypervolaemia harms SAH patients.
   • This stunning usually recovers; ICU ventilation and serial echo. After surgery