Anesthetic Considerations

The anesthetic management of patients with ICH can be complex, depending on the patient's neurologic status, the size of the ICH, and its systemic manifestations, as well as the preexisting comorbidities.

Decrease in level of consciousness might indicate elevated ICP, which can lead to nausea and vomiting, resulting in pneumonitis. The high ICP might invoke Cushing's reflex, with increased systemic blood pressure and bradycardia, possibly accompanied by systemic hypo-volemia. Induction of general anesthesia in these patients can result in catastrophic systemic hypotension.

Most patients presenting for surgical evacuation of ICH have decreased neurologic status and high ICP, necessitating endotracheal intubation and mechanical ventilation before being taken to the operating room. In those who are not intubated, induction of anesthesia and intubation of trachea can be accomplished with thiopental, propofol or etomidate, and succinylcholine or rocuronium, using a rapid-sequence technique. Direct arterial blood pressure monitoring should be instituted in addition to routine monitoring. Central venous pressure monitoring might be indicated in patients who are hypovolemic and in those with cardiac disease. Anesthesia can be maintained with propofol infusion for maximal cerebral vasoconstriction or low-dose inhaled anesthetics under mild hyperventilation. The choice might be dependent on the operating conditions. Fluid and electrolytes, as well as serum glucose, must be monitored intraoperatively, because the use of mannitol and hypertonic saline might result in electrolyte disturbances.

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