|Year : 2008 | Volume
| Issue : 2 | Page : 199-201
Ventricular Tachycardia due to Intranasal Adrenaline in Nasal Surgery- a Case Report
HA Hema1, Anand Kulkarni2, RK Ranjan3, M Ambareesha4
1 Senior Resident, Department of Anaesthesiology, Kasturba Medical College, Mangalore 575 001, Karnataka, India
2 Assistant Professor, Department of Anaesthesiology, Kasturba Medical College, Mangalore 575 001, Karnataka, India
3 Associate Professor, Department of Anaesthesiology, Kasturba Medical College, Mangalore 575 001, Karnataka, India
4 Professor and Head, Department of Anaesthesiology, Kasturba Medical College, Mangalore 575 001, Karnataka, India
|Date of Acceptance||03-Mar-2008|
|Date of Web Publication||19-Mar-2010|
R K Ranjan
504, Classique Apartments, Bunts Hostel Road, Mangalore 575 003
Source of Support: None, Conflict of Interest: None
We present the case of 32-year-old female with chronic sinusitis undergoing functional endoscopic sinus surgery(FESS), who developed ventricular tachycardia following intranasal adrenaline pledgets which was successfully treated with defibrillation.
Keywords: Epinephrine; Ventricular tachycardia; Defibrillation
|How to cite this article:|
Hema H A, Kulkarni A, Ranjan R K, Ambareesha M. Ventricular Tachycardia due to Intranasal Adrenaline in Nasal Surgery- a Case Report. Indian J Anaesth 2008;52:199-201
|How to cite this URL:|
Hema H A, Kulkarni A, Ranjan R K, Ambareesha M. Ventricular Tachycardia due to Intranasal Adrenaline in Nasal Surgery- a Case Report. Indian J Anaesth [serial online] 2008 [cited 2020 Nov 27];52:199-201. Available from: https://www.ijaweb.org/text.asp?2008/52/2/199/60622
| Introduction|| |
Vasopressors have a long history of use as hemostatic agents during nasal surgery. Earlier cocaine was preferred for its surface anaesthetic property and unique vasoconstrictive effects.
Drugs like epinephrine, phenylephrine, norepinephrine, vasopressin analogues and oxymetazoline are presently used as adjuvants with local anaesthetics to prepare the nasal passages before nasal surgery and for nasal intubation. Epinephrine acts as a vasoconstrictor of capillaries and is considered to be the vasoconstrictor of choice with local anaesthetics  . Epinephrine also prevents toxicity by reducing the systemic absorption of local anaesthetics from the nasal mucosa and prolonging the duration of action as well as the intensity of a nerve block produced by local anaesthetics.
The instillation of local anaesthetics with or without vasopressors is used routinely by ENT surgeons to prepare nasal passages prior to FESS and other surgeries. We describe a patient who developed ventricular tachycardia after intranasal adrenaline pledgets scheduled for nasal surgery under local anaesthesia
| Case report|| |
A 32-year-old female, ASA grade 1 with history of right sided headache and diagnosed as chronic sinusitis was scheduled for functional endoscopic sinus surgery (FESS) under local anaesthesia.
Patient was premedicated by ENT surgeon with atropine 0.6mg and promethazine 25 mg intramuscularly 1 hour before shifting the patient. Right nostril was packed with 4% lidocaine with adrenaline (6mg) and pethidine 75 mg was given intravenously. Additional 2% lidocaine with adrenaline (1: 1000 ) was infiltrated and partial right middle turbinectomy done. Patient then complained of pain to which the surgeon requested for general anaesthesia.
Patient was premedicated with fentanyl 50 mcg, midazolam 1.5mg and glycopyrrolate 0.2mg. Cardioscope, pulse oximetry and non invasive blood pressure were attached. Patient was preoxygenated with 100% oxygen for 3 minutes and was induced with thiopentone 5 mg.kg -1 and succinylcholine 2mg.kg -1 . Patient immediately had a run of broad complex ventricular tachycardia. An intravenous bolus of 100mg preservative free lidocaine was given. Endotracheal intubation was done with 7.5 mm cuffed tube. Heart rhythm was not reverted. DC shock 300J was given. Heart rhythm reverted to sinus rhythm. Patient was maintained on 100% oxygen and positive pressure ventilation was instituted. Patient again had a run of broad complex ventricular tachycardia which was again reverted back to normal rhythm with DC shock 300 J. She had normal sinus rhyhm with heart rate of 100/min, blood pressure of 90/60 mm Hg, SpO 2 95%. Dopamine infusion was started at 7mcg.kg -1 .min -1 which was titrated according to blood pressure. Arterial blood gas analysis and ECG were within normal limits. Surgery was not proceeded further.
After patient regained consciousness and with a SpO 2 of 98% patient was extubated. Patient was shifted to ICU. ECHO showed normal study with EF- 64%.
Postoperative period was uneventful. Patient was discharged on the 6th post operative day.
| Discussion|| |
Surgical dissection of nasal mucosa causes bleeding and initiates potent cardiovascular reflexes mediated through the trigeminal nerve.  In an attempt to establish asanguineous field, lidocaine with vasopressors is instilled into the nasal cavity. The use of vasopressor is not without complications and may put the patient at risk.
Cocaine was traditionally used for its surface anaesthetic and vasoconstriction properties, which provided hemostasis.  With reports of complications linked to medical and recreational use of cocaine, various other local anaesthetics were introduced. Because of the inherent vasodilatory properties of local anaesthetics, epinephrine was added to ensure vasoconstriction and thus prolong the action of local anaesthetics.
Although epinephrine activates presynaptic a 2 adrenergic receptors, its mechanism for prolonging the duration of local anaesthetic clearance and not on pharmacodynamically mediated potentiation of local anaesthetics  .Various studies have demonstrated that topical application of local anaesthetics with epinephrine is as good, if not better than just topical cocaine. ,
The â1 effects of epinephrine include tachycardia and increase myocardial contractility, while the stimulation of a 1 receptors would cause an increase systematic and pulmonary vascular resistance. The increase in myocardial oxygen demand in the face of limited perfusion may result in either ischemia or an infarction. Epinephrine induced coronary vasospasm may also precipitate acute myocardial infraction.  Other complications arising from the use of local anaesthetics with epinephrine include local tissue necrosis.
Savino et al reported 4 patients undergoing nasal surgery, all of whom developed permanent visual field defects after administration of local anaesthetic with epinephrine into nasal cavity. The postulated mechanism for this is vasospasm of the retinal vessels  .
In 1992, Perusse et al published a review of cardiac contraindications to the use of vasoconstrictors in dentistry. Absolute contraindication include unstable angina, recent MI, recent coronary artery bypass surgery, refractory arrhythmias, severe hypertension, uncontrolled congestive heart failure.  However the use of epinephrine may be indicated in certain of these contraindications after closely weighing the risks versus the benefits of using vasopressors.
By minimizing the concentration of epinephrine, we may be able to attenuate the effects of accidental intravascular injection or rapid systemic absorption of vasoconstrictors. It has been recommended in head and neck surgery that epinephrine in concentration of 1: 2,00,000 or 1:4,00,000 be used for optimal hemostasis. 
Most clinical evidence suggests that increase the epinephrine concentration beyond 5mcg.ml -1 (1:2,00,000) does not result in a stronger vasoconstriction effect, but does increase toxic circulatory side effects. 
Milam and Giovanniti suggest that doses of epinephrine should not exceed 3mcg.kg -1 upto a total doses of 200mcg in healthy patients and with dose reductions for patient with cardiovascular disease.  Nonetheless, the occasional patient may unexpectedly manifest extreme sensitivity to injected epinephrine in doses within recommended guidelines. 
Alternatively, nasal decongestants such as oxymetazoline, a selective a 1 agonist, have been used for nasal decongestation and have been found to be more effective vasoconstrictors than cocaine, lidocaine or phenylephrine. , The management of epinephrine induced toxicity should be directed toward prompt detection and early treatment of adverse effects.
We suggest that personnel administering these drugs do so with caution, paying particular attention to the concentration of epinephrine and that dosages be strictly restricted below toxic levels. Haemodynamic variables should be closely monitored during injection of any vasopressor.
| References|| |
|1.||Jage.J. Circulatory effects of vasoconstrictors combined with local anaesthetics. Anaesth Pain control Dent 1993;2: 81-6. |
|2.||Abou- Madi MN, Trop D , Barnes J. Aetiology and control of cardiovascular reactions during trans sphenoidal resection of pituitary microadenoma Can Anaesth Soc J 1980 ;27:491-5. |
|3.||Fleming JA , Byck.R, Barash PG. Pharmacology and therapeutic application of cocaine. Anesthesiology 1990;73:518-31. |
|4.||Bernards CM, Kopacz DJ. Effects of epinephrine on lidocaine clearance in vivo; a microdialysis study in humans. Anesthesiology 1999; 91:962-8. |
|5.||Myers RR, Heckman HM. Effects of local anaesthetics on nerve blood flow: studies using lidocaine with and without epinephrine. Anesthesiology 1989;7: 757-62. |
|6.||Kasemsuwan L, Griffiths MV. Lignocaine with adrenaline: Is it as effective as cocaine in rhinological practice? Clin Otolaryngol 1996: 21:127-9. |
|7.||Raster JF, Chow JM, Vasoconstricative effects of cocaine and lidocaine with epinephrine in hamster pouch model. Otolaryngol Head and Neck surgery 1994;111;795-8. |
|8.||Ferry DR, Henry RL , Kern MJ. Epinephrine induced myocardial infarction in a patient with angiographically normal coronary arteries.Am Ht 1986; 111: 119-5. |
|9.||Savino PJ,Burde RM, Mills RP. Visual loss following intranasal anaesthetic injection. J clin Neuroopthalmol 1990;10:140-4. |
|10.||Perusse R, Goulet JP, Turcotte JY. Contraindications to vasoconstrictors in dentistry: part 2. Oral Surg Oral Med Oral Pathol 1992;74:679-86. |
|11.||Dunlevy TM, O' Malley TP, Postma GN. Optimal concentration of epinephrine for vasoconstriction in neck surgery. Laryn goscope 1996;106: 1412-14. |
|12.||Carpenter RL, Mackey DC. Local anaesthetics. In: Barash PG, Cullen BF,Stoelting RK (Eds.)Clinical Anaesthesia. 3rd ed.Philadelphia: JB Lippincott 1997:413-440. |
|13.||Milam SB, Giovannitti JA .Local anesthetics in dental practice. Dent Clin North Am 1984;28:493-508. |
|14.||Wanamaker HH, Arandia HY, Wanamaker HH. Epinephrine hypersensitivity induced cardiovascular crisis in otologic surgery. Otolaryngol Head Neck Surg 1994;111:841-4. [PUBMED] [FULLTEXT] |
|15.||Riegle EV, Gunter JB, Lusk RP, et al. A comparision of vasoconstrictors for functional endoscopic sinus surgery in children. Laryngoscope 1992;102:820-3. [PUBMED] [FULLTEXT] |
|16.||Katz RI, Hovagim AR, Finkelstein HS, et al. Comparison of cocaine, lidocaine with epinephrine and oxymetazoline for prevention of epistaxis on nasotracheal intubation. J Clin Anaesth 1990;2:16-20. |