A patient of terson's syndrome for ocular surgery: Perianesthetic concerns
A 55-years-old male weighing 60 kg was diagnosed with bilateral vitreous hemorrhage and scheduled for pars plana vitrectomy. He was known hypertensive since 1 year and was managed with oral amlodipine (5 mg) twice a day and losartan (50 mg) once a day. Since 4 months, patient started having progressively increasing loss of vision and memory loss which was followed by sudden onset headache associated with vomiting and subsequently loss of consciousness. Pupils of left eye were dilated and sluggishly reacting while right eye was of normal size and sluggishly reacting. Magnetic resonance imaging (MRI) of head revealed left frontal intracranial hemorrhage with intraventricular extension. Diagnosis of stroke with left frontal bleed was made. He was kept on conservative management with continuation of antihypertensive drugs. The patient's consciousness gradually improved. GCS was E4 M6 V5, motor power was 5/5 with down going planters. He had a full recovery after 1 month. The vision did not improved and there was progressively increasing loss of vision. On further evaluation, it revealed hypertensive bleed in the eye and magnetic resonance angiography was done which could not rule out aneurysmal bleed. He was planned for pars plana viterectomy.\nPreoperatively, patient was conscious and maintaining vitals. His routine investigations including 12 lead electrocardiogram, chest X-ray, hemogram, liver, and kidney function test were normal. His antihypertensive drugs were continued and was premedicated with oral alprazolam (0.5 mg) night before the surgery. He was also administered oral ranitidine (150 mg) night before the surgery and in the morning after the surgery. A fasting status of 6 h for solid food and 2 h of clear fluid was advised.\nIn the operating room, monitors including 5 lead electrocardiogram, non invasive automated blood pressure, and pulse oximeter were attached. After securing intravenous access, intravenous midazolam (1 mg) and fentanyl (120 μg) were administered. Anesthesia was induced with propofol (120 mg) and lungs were ventilated with 3% sevoflurane in nitrous oxide and oxygen (50:50). After achieving neuromuscular blockade with rocuronium (40 mg) and intravenous administration of preservative lidocaine (60 mg), airway was secured with proseal laryngeal mask airway (PLMA). Anesthesia was maintained with sevoflurane in nitrous oxide and oxygen (MAC 1) and boluses of rocuronium (10 mg) and fentanyl (20 μg). After the surgery, the residual neuromuscular blockade was reversed with neostigmine (2.5 mg), glycopyrollate (0.4 mg) and PLMA was removed after adequate respiratory efforts were present. The patient had an uneventful recovery and discharged 3 days later for further follow up in ophthalmology and neurology clinics.