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Coronary vasospasm caused by local infiltration of epinephrine after spinal anesthesia.

Lee MG, Park HY, Lee CK, Choi JH, Choi YS - Korean J Anesthesiol (2014)

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Gachon University Gil Hospital, Incheon, Korea.

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Local infiltration of epinephrine at the surgical site has been widely used to improve the operating view, due to reduced blood loss caused by vasoconstriction... She had no previous medical history... Preoperative electrocardiogram (ECG), chest X-ray, and blood chemistry were found to be normal... An ECG showed tachyarrhythmia, and the HR and BP rose to 160 beats/min and 210/130 mmHg, respectively... Esmolol 30 mg was instantly injected intravenously (IV), but the patient's vital signs did not change... An ECG showed ST segment depression in leads II, III, and aVF... The blood levels of creatine kinase MB and troponin T were found to be 6.9 ng/ml and 0.347 ng/ml, respectively... Blood catecholamine levels were not known in our case, but following the administration of epinephrine SC, there was an interval during which the increased BP was dramatically decreased over time, which can be assumed to be the cause of the coronary spasm... In reviewing the adverse effects of epinephrine administration in the alert state, it has been found that coronary artery spasm occurred in most cases when the patients complained of chest pain... In order to treat coronary artery spasm, it is necessary to monitor and observe the patient continuously while controlling the BP with an IV nitrate infusion, IV morphine administration, and IV fluid infusion, and most patients have been discharged in a stable state after a few days... Although the patient in this case was injected with 1 mg of epinephrine mixed with normal saline SC, which can be regarded as a relatively safe dose for clinical use, epinephrine can be absorbed rapidly through cervical mucus where there is increased blood flow... It has been known that using epinephrine diluted with lidocaine rather than with normal saline decreases the incidence of ventricular arrhythmias due to the protective effect of lidocaine on epinephrine... Esmolol, a short-acting β1-selective blocker, can reduce the risk of hypertension and coronary spasm due to unopposed α-adrenergic stimulation, and it can be used to control catecholamine surges precisely... However, in cases in which epinephrine was administered for operative procedures during spinal anesthesia, most patient complaints of chest pain are caused by coronary artery spasm, and immediate confirmation of coronary spasm is important for proper management.

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Emergency coronary angiography shows a filling defect in the distal LAD and compression in the mid-LAD (A), which is relieved by intracoronary nitroglycerin injection (B). LAD indicates left anterior descending coronary artery.
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Figure 1: Emergency coronary angiography shows a filling defect in the distal LAD and compression in the mid-LAD (A), which is relieved by intracoronary nitroglycerin injection (B). LAD indicates left anterior descending coronary artery.

Mentions: After arrival in the recovery room, the patient's SpO2 was 100% and HR was 81 beats/min, but the BP decreased to 75/44 mmHg. After two injections of ephedrine 5 mg IV, the BP increased to 93-108/61-75 mmHg, but the patient complained of chest pain. An ECG showed ST segment depression in leads II, III, and aVF. The blood levels of creatine kinase MB and troponin T were found to be 6.9 ng/ml and 0.347 ng/ml, respectively. Emergency coronary angiography showed a spasm of the left anterior descending coronary artery (LAD), and coronary artery expansion was confirmed following injection of 200 µg of intracoronary nitroglycerin (Fig. 1). The patient's chest pain subsided instantly and echocardiography showed normal findings. She received oral administration of nitroglycerin, tramadol, and diltiazem in the ward. Five days after the surgery, the patient was discharged with a prescription for sublingual nitroglycerin. Despite two months' follow-up after discharge, there were no other problems, and her chest pain did not recur.


Coronary vasospasm caused by local infiltration of epinephrine after spinal anesthesia.

Lee MG, Park HY, Lee CK, Choi JH, Choi YS - Korean J Anesthesiol (2014)

Emergency coronary angiography shows a filling defect in the distal LAD and compression in the mid-LAD (A), which is relieved by intracoronary nitroglycerin injection (B). LAD indicates left anterior descending coronary artery.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4295977&req=5

Figure 1: Emergency coronary angiography shows a filling defect in the distal LAD and compression in the mid-LAD (A), which is relieved by intracoronary nitroglycerin injection (B). LAD indicates left anterior descending coronary artery.
Mentions: After arrival in the recovery room, the patient's SpO2 was 100% and HR was 81 beats/min, but the BP decreased to 75/44 mmHg. After two injections of ephedrine 5 mg IV, the BP increased to 93-108/61-75 mmHg, but the patient complained of chest pain. An ECG showed ST segment depression in leads II, III, and aVF. The blood levels of creatine kinase MB and troponin T were found to be 6.9 ng/ml and 0.347 ng/ml, respectively. Emergency coronary angiography showed a spasm of the left anterior descending coronary artery (LAD), and coronary artery expansion was confirmed following injection of 200 µg of intracoronary nitroglycerin (Fig. 1). The patient's chest pain subsided instantly and echocardiography showed normal findings. She received oral administration of nitroglycerin, tramadol, and diltiazem in the ward. Five days after the surgery, the patient was discharged with a prescription for sublingual nitroglycerin. Despite two months' follow-up after discharge, there were no other problems, and her chest pain did not recur.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Pain Medicine, Gachon University Gil Hospital, Incheon, Korea.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Local infiltration of epinephrine at the surgical site has been widely used to improve the operating view, due to reduced blood loss caused by vasoconstriction... She had no previous medical history... Preoperative electrocardiogram (ECG), chest X-ray, and blood chemistry were found to be normal... An ECG showed tachyarrhythmia, and the HR and BP rose to 160 beats/min and 210/130 mmHg, respectively... Esmolol 30 mg was instantly injected intravenously (IV), but the patient's vital signs did not change... An ECG showed ST segment depression in leads II, III, and aVF... The blood levels of creatine kinase MB and troponin T were found to be 6.9 ng/ml and 0.347 ng/ml, respectively... Blood catecholamine levels were not known in our case, but following the administration of epinephrine SC, there was an interval during which the increased BP was dramatically decreased over time, which can be assumed to be the cause of the coronary spasm... In reviewing the adverse effects of epinephrine administration in the alert state, it has been found that coronary artery spasm occurred in most cases when the patients complained of chest pain... In order to treat coronary artery spasm, it is necessary to monitor and observe the patient continuously while controlling the BP with an IV nitrate infusion, IV morphine administration, and IV fluid infusion, and most patients have been discharged in a stable state after a few days... Although the patient in this case was injected with 1 mg of epinephrine mixed with normal saline SC, which can be regarded as a relatively safe dose for clinical use, epinephrine can be absorbed rapidly through cervical mucus where there is increased blood flow... It has been known that using epinephrine diluted with lidocaine rather than with normal saline decreases the incidence of ventricular arrhythmias due to the protective effect of lidocaine on epinephrine... Esmolol, a short-acting β1-selective blocker, can reduce the risk of hypertension and coronary spasm due to unopposed α-adrenergic stimulation, and it can be used to control catecholamine surges precisely... However, in cases in which epinephrine was administered for operative procedures during spinal anesthesia, most patient complaints of chest pain are caused by coronary artery spasm, and immediate confirmation of coronary spasm is important for proper management.

No MeSH data available.