|
Intraoperative Pulseless Electrical Activity and Acute Cardiogenic Shock After Administration of Phenylephrine, Epinephrine, and Ketamine As originally published in The Ochsner Journal, 10:205-209, 2010
By: Dr. Adam Kaye, PharmD, Alan Kaye, MD, PhD, A. Sabartinelli, MD, A. Holtzman, CRNA, P. Samm, MD |
ABSTRACT
The use of phenylephrine has been well described as a potential cause of morbidity and mortality. A thorough literature review of phenylephrine use is presented in this article. The use of ketamine and epinephrine with phenylephrine can precipitate an even more potentially lethal and catastrophic syndrome. We present the case of a 21-year-old man with Hodgkin's lymphoma and lupus who experienced an abrupt hypertensive crisis followed by pulseless electrical activity and cardiogenic shock after application of 2.5% phenylephrine-soaked nasal pledgets prior to excision of a large nasopharyngeal tumor. This case report adds to the current literature on the potential dangers of phenylephrine in clinical practice and describes a case of reversible severe left ventricular dysfunction in the setting of excessive pharmacologically induced sympathetic stimulation.INTRODUCTION
Phenylephrine is an ∝-agonist with a wide array of effects on the body. The drug has multiple indications and is employed in varied medical disciplines. Intraoperative use of topical ∝-agonist agents for vasoconstriction is common in ear, nose, and throat (ENT)1 and ophthalmologic2 procedures and has been increasingly used in arthroscopic surgeries.3 Use of this drug is not without risks because severe cardiopulmonary complications can occur if local administration reaches the systemic circulation. Such an occurrence comprises the case reported here. We present a case of pulseless electrical activity (PEA) and cardiogenic shock following hypertensive crisis induced by absorption of 2.5% phenylephrine, an ∝-agonist, soaked onto nasal pledgets. This drug was administered in preparation of an ENT nasopharyngeal tumor excision in a 21-year-old man without known preexisting cardiac dysfunction. Signed consent was obtained from the patient in question prior to writing this case report.CASE REPORT
A 21-year-old man (57 kg, 180 cm) was scheduled for surgical debulking and excisional biopsy of an aggressive nasopharyngeal mass under general anesthesia. The procedure was intended to establish a definitive diagnosis and to establish a nasal airway. The patient had a history of multiple tumors with a nondiagnostic biopsy in the emergency department. His past medical history was also significant for anemia (hematocrit 28% after transfusion) and thrombocytopenia (156/mm3 after transfusion) requiring recent blood transfusion, systemic lupus erythematosus treated with prednisone (30 mg/d and hydroxychloroquine 200 mg/d), and recent excision of a necrotic pelvic mass that was later diagnosed as nonsclerosing Hodgkin's lymphoma. The patient complained of persistent breathing difficulties, altered speech, and dysphagia. On examination, he was awake, spontaneously mouth breathing, and resting comfortably. Airway evaluation revealed bilateral nasal airway obstruction approaching 100%. The oropharynx was obstructed by a large mass measuring approximately 8 cm that was abutting the soft palate. The patient could open his mouth to 3 fingerbreadths but was unable to fully extend his neck. The remainder of the physical examination was unremarkable except for a mild tachycardia of 104 beats per minute (bpm). Preoperative evaluation, including complete blood count, electrolyte studies, coagulation studies, and electrocardiogram, revealed no additional abnormalities. No additional cardiac work-up was performed or deemed warranted.Prior to induction, standard American Society of Anesthesiologists monitors were applied and initial vital signs were stable (blood pressure [BP], 117/ 90 mmHg; heart rate, 112 bpm; respiratory rate, 14 breaths per minute; and oxygen saturation, 100%). Midazolam, 2 mg intravenously (IV), was administered to the patient in the holding area to allay preoperative anxiety. Methylprednisone, 125 mg IV, was administered for adrenal insufficiency prophylaxis prior to induction. Ketamine, in divided doses totaling 100 mg, and a dexmedetomidine infusion, in a dose range of 1 to 3 mg/kg, were started prior to induction, and both transtracheal and superior laryngeal blocks were performed using 4% and 1% lidocaine, respectively. A fiberoptic intubation was done using a 7.0-mm oral RAE tube. Anesthesia induction was facilitated with an additional dose of ketamine, 100 mg IV; rocuronium, 50 mg IV, was administered to facilitate paralysis. Maintenance of anesthesia was facilitated with sevoflurane, in a dose range of 1.8% to 2%.
Dr. Adam Kaye, PharmD, is a California Licensed Pharmacist and a Clinical Associate Professor of Pharmacy Practice at University of the Pacific's Thomas J. Long School of Pharmacy. He has also been employed by a national pharmacy company since 1992 and has served as a Pharmacy Manager since 1997.
©Copyright - All Rights Reserved
DO NOT REPRODUCE WITHOUT WRITTEN PERMISSION BY AUTHOR.
