Anesthetic Management of a Neonate with Subdural Hematoma

Jili Basing, Ashish Bindra, Niraj Kumar
2019 Journal of Neuroanaesthesiology and Critical Care  
We report anesthetic management of a 7-day old, 3-kg male infant admitted to our hospital with complaints of poor feeding, lethargy (Glasgow coma scale [GCS] E1V1M5), and seizure. The baby was born via normal vaginal delivery and was apparently healthy at birth. There was no significant antenatal history or history of any drug intake during pregnancy. Noncontrast computed tomography (NCCT) of the head at admission revealed a large fronto-temporo-parietal subdural hematoma (SDH) in the left
more » ... H) in the left side, warranting urgent surgical intervention (►Fig. 1). Preoperative international was done with fentanyl, oxygen, sevoflurane, and rocuronium. Right internal jugular vein and right femoral artery were cannulated for intravenous access and invasive BP monitoring, respectively. Intraoperative monitoring included 5-lead electrocardiogram (ECG), invasive BP, central venous pressure, pulse oximetry, temperature, urine output, and arterial blood gas (ABG) analysis. Fentanyl 1.5 µg/h and cisatracurium 0.3 mg/h with sevoflurane were used for maintenance of anesthesia. Normocarbia and normothermia were targeted. Intraoperative ABG analysis showed normal gas exchange with hemoglobin (Hb) of 5 g/dL and blood glucose of 158 mg/dL. There were two episodes of intraoperative hypotension, which were managed with blood or fluid bolus and mephentermine 0.3 mg. A total of 180 mL of crystalloid was given intraoperatively. Blood loss was estimated to be 200 mL and was replaced with equal amount packed red blood cells (RBCs), platelets, and fresh frozen plasma (FFP) (15 mL/kg). Toward the end of surgery (decompressive craniotomy), BP dropped again (40/28 mm Hg) and an infusion of noradrenaline 1 µg/min was started. The patient was shifted to the intensive care unit (ICU) for elective ventilation with HR 160 beats/min, BP 80/46 mm Hg, and temperature 35.2°C on noradrenaline infusion. Removal of SDH alone could not ensure adequate recovery due to complex multisystem effect of neurological injury. The patient was kept sedated and mechanically ventilated in postoperative period. Monitoring in ICU included 5-lead ECG, invasive BP, central venous pressure, pulse oximetry, temperature, urine output, and ABG analysis, along with monitoring of neurological status and postoperative hematological and biochemical investigations. The patient's BP dropped further, and dopamine infusion was started as well. Investigations revealed coagulopathy with deranged prothrombin time, INR of 3, and platelet count of 62,000/mm 3 . Both platelets and FFP were transfused. Postoperative CT revealed removal of hematoma with evolving infarct. Despite all the steps taken to maintain hemodynamics and correct coagulopathy, the patient could not make it and succumbed to his injuries on first postoperative day. Incidence of SDH in newborns is reported to be as high as 48%; however, SDH requiring surgical decompression is J Neuroanaesthesiol Crit Care Fig. 1 Computed tomography scan showing fronto-temporo-parietal hematoma on the left side. normalized ratio (INR) was 1.03 and the platelet count was 1,06,000/mm 3 . In operating room, the patient was received with tracheal tube of 3.5-mm ID in situ and a respiratory rate of 30 breaths/min, heart rate (HR) of 150 beats/min, and blood pressure (BP) of 80/40 mm Hg. Anesthetic induction
doi:10.1055/s-0039-1693500 fatcat:qcomeasy3bfixnlt4mm7vobd6a