Perioperative Management of Atrial Fibrillation In a Geriatric Neurosurgical Patient With Acute Aneurysmal Subarachnoid Hemorrhage.

Aneurysmal subarachnoid hemorrhage (SAH) is a complex multifaceted neurosurgical emergency with cardiopulmonary complications. Concurrent atrial fibrillation seen commonly in the geriatric population further challenges perioperative management. Osmotherapeutic agents such as mannitol are routinely used in SAH to decrease intracranial pressure by withdrawing water from the brain parenchyma into the intravascular space. However, mannitol also has the potential to cause myocardial dysfunction and exacerbation of arrhythmias like atrial fibrillation in geriatric patients with decreased cardiovascular reserve. The literature on goal-directed fluid therapy and transesophageal echocardiography (TEE)-guided intraoperative management of a case of atrial fibrillation is sparse. This case report highlights the role of mannitol in the potentiation of arrhythmias like atrial fibrillation which was then successfully managed using goal-directed fluid therapy and TEE leading to a favorable outcome.