Emergency craniotomy in anticoagulated patient 抗凝病患与开颅手术麻醉

shenxiu2

A 65 years old woman, with history of chronic atrial fibrillation and ischaemic stroke, is on long term warfarin. She presents with sudden onset of headache and right sided weakness. Cranial CT showed a left sided intra-cerebral haematoma. Her INR is 4.2.

1) Discuss the important issues in emergency evaluation and management of this patient.

2) Discuss the treatment options for the reversal of the warfarin anticoagulation in this patient.

3) This patient is to undergo emergency craniotomy and evacuation of the intra-cerebral haematoma. Compare and contrast the use of propofol and sevoflurane for maintanence of anaesthesia in this patient.


Hong Kong Board final exam question 2, 2009 March

1001

前不久碰到一类似病人，感受颇深。
这种病人对外科和麻醉医生来说都是一个两难的选择，凝血功能障碍对神外来说算是手术禁忌，但是不做手术的话，颅内的出血可能直接要了病人的命。所以，个人觉得是否手术还是交给外科定。
如果手术的话：
1、首先考虑的应该是立即改善凝血功能，INR 4.2应该是过分抗凝了，考虑预防血栓，控制INR到2左右可能比较合适。
2、如情况紧急，停用华法林并用VitK对抗起效可能慢，个人觉得大量补凝血因子效果会较快，因为华法林对血液中已有的凝血因子 Ⅱ、Ⅶ、Ⅸ、Ⅹ并无抵抗作用。
3、就神外麻醉而言个人还是选择用静脉麻醉药。至于丙泊酚和七氟烷对凝血功能的影响感觉有点空白，希望大家补充。