Anesthetic management of a patient with hemophilia A with spontaneous acute subdural hematoma
A 50-year-old, 70 kg, man presented with loss of consciousness for the last 12 hours. The patient was a known case of Hemophilia A, having previous history of spontaneous bleeding into joints, and had received Factor VIII twice. The patient was receiving analgesics for back pain. He was a hypertensive on irregular medications. There was no history of trauma or drug abuse or any other surgery in the past.\nThe patient's heart rate was 56/min and blood pressure 118/78 mmHg. Glasgow Coma Scale (GCS) score was E1M2V1 and pupils were bilaterally mid-dilated, not reacting to light. Patient's hemoglobin was 11.1 gm/dl, INR 1.61 and APTT 150 sec. Non-contrast computerized tomography (CT) scan showed an acute left temporoparietal sub-dural hematoma (SDH) with left frontal hematoma, with mass effect and a midline shift of 10 mm.\nAfter shifting to the neurosurgery intensive care unit (ICU), patient was administered intravenous (IV) fentanyl 200 mcg, propofol 100 mg, vecuronium 8 mg and lignocaine 100 mg. Patients trachea was intubated and lungs mechanically ventilated. Neuroprotective measures in the form of mannitol (1 gm/kg, IV, TDS), dexamethasone (8 mg, IV, BD), seizure prophylaxis (phenytoin 100 mg, IV, TDS) and hyperventilation (to a PCO2 of 32 mmHg) were initiated. The patient was scheduled for an emergency craniotomy and clot evacuation after stabilizing his coagulation parameters. Hematology consultation was taken and 11 vials (3000 units) of factor VIII concentrate (Hemofil M, Baxter) were transfused. His APTT was 26 sec two hours later and he was taken up for surgery.\nInside the operation theater, a 16G peripheral line was taken. His left radial artery was cannulated. Right internal jugular vein triple lumen catheter was put under ultrasound guidance for central venous pressure monitoring, and in anticipation of major blood loss. Monitoring included pulse-oximetry, electrocardiogram, end-tidal carbon dioxide, arterial blood gas (ABG) monitoring, temperature monitoring (oropharyngeal) and urine output. Bilateral scalp block was given. Anesthesia was maintained with oxygen, air and isoflurane. The patient received fentanyl (200 mcg IV at the start of the surgery and another 100 mcg IV later, total dose 4 mcg/kg) for analgesia and vecuronium (0.1 mg/kg initially and the 0.01 mg/kg IV every 30 min) for muscle relaxation. 200 ml (3 ml/kg) of 3% saline was given over 30 minutes for brain relaxation at scalp incision.[]\nThe patient received 1 vial (≈272 units) of Hemofil M every 2 h during surgery. 750 mg of tranexamic acid was also given. Blood loss was 900 ml. No PRBC transfusion was required. Serial ABG analysis showed no major acid-base imbalance. The patient remained hemodynamically stable throughout the surgery and was shifted back to ICU for postoperative elective ventilation. Post-operative analgesia was provided with IV fentanyl and paracetamol. Serum Na+ levels were measured 4-6 hourly in the postoperative Day 1 and 2. In case Na+ concentration was <155 mEq/L, we infused 200 ml of 3% saline. Our aim was to maintain Na+ level between 150-160 mEq/L. A total of 7 doses were given in the next 48 hours. In general, an infusion of 1 mL/kg of 3% saline raises the serum Na+ by approximately 1 mEq/L, regardless of baseline serum Na+ concentration.[]\nOne vial of Hemofil M was given 2 hourly to the patient in the 1st postoperative day and 3 hourly from the 2nd day. Tracheostomy was done on the 2nd postoperative day. Patient showed signs of neurological improvement on the 2nd day, with GCS improving to E2M3VT, and was weaned off the ventilator on the 4th day. The factor VIII level was 64% on the 5th postoperative day and 46% on the 14th day. HEMOFIL M was continued till the 14th day. On the 21st postoperative day the factor VIII level was 39%. There was no postoperative hemorrhage. The GCS improved to E3M5VT by the 21st day but the patient had right hemiplegia.