Bad, bad situation
I hope surgeons had frank discussion with family.
Is patient already tubed ?
Burr holes under local not an option?
If crani only option and case a go she gets PAC if time. If not tubed I would use ketamine. If no time because decompensating fast; to OR. Art at least if she doesn't have one. While surgeons prepping I place big femoral line. Could float PA from there as well. Have Milrinone and blood available.
Pray.
Just some initial thoughts but hemorrhagic conversion in an lvad pt is muy malo.
Indeed a crappy situation. Family not yet in hospital unfortunately. Not intubated. GCS of 9ish. Surgeon adamant that EVD and craniotomy for evacuation of hematoma is optimal plan. Patient had been reversed with protamine and given Vit K already (yikes). LVAD nurse accompanied patient into OR. Thankfully patient had actually regained some heart function and and was being considered for LVAD wean to explant.
A smattering of the issues running through my head at the time:
-Reversed anticoagulation in a patient with an LVAD (high risk for catastrophic thrombosis)
-Raised ICP with intracranial hemorrhage: need to maintain CPP but avoid worsening bleeding
-Considerations of LVAD: sensitive to drops in preload and increases in afterload (and numerous other concerns for LVAD patient, including risky compressions if arrest)
-MELAS considerations
Despite some faint pulsatility, took us about 30 min to get art line with US. Large bore IV's. Blood up. Off to sleep with remi, etomidate and small dose roc. Hemodynamic rock solid through induction. CVC post induction. Maintained with 1/2 mac des and remi infusion. Transthoracic echo prn.
FYI, my MELAS considerations:
1) Multisystem disease including stroke-like episodes, muscle weakness, cardiomyopathy, propensity for metabolic abnormalities (acidosis, diabetes)
2) Pharmacologic implications:
i) No sux (esp if neuropathy/myopathy w/ risk for hyperkalemia; largely debunked link btwn mitochondrial myopathy and MH)
ii) Cautious and judicious use of all sedating/analgesic meds (sensitive and may have very prolonged effect; acidosis)
iii) Judicious NMB (baseline muscle weakness; may have prolonged effect)
She very suprisingly did quite well. Very slow to wake from even that minimal anesthetic but was able to extubate her about 6h postop and she recovered well and left hospital. One of the more interesting cases of my residency.
