Reactions 1214 - 9 Aug 2008

SEphedrine/epinephrine/phenylephrine

Tako-Tsubo cardiomyopathy: case reportA 35-year-old woman, who had been transferred for labour

induction, developed Tako-Tsubo cardiomyopathy afterreceiving epidural epinephrine [adrenaline] as part ofcombined spinal epidural analgesia (CSE), epinephrine andphenylephrine.

The woman underwent CSE placement and receivedbupivacaine and fentanyl. About 10.5 hours later, she wasprepared for a caesarean section. A bolus of lidocaine 5mLwith bicarbonate, and 1:200 000 epinephrine [dosage notstated] was administered via the epidural catheter. Sheachieved an anaesthesia level of T6 and had an initial BP of110/50mm Hg, cycling every 2 minutes. During the second BPcycle, she reported feeling unwell and received preemptiveephedrine 10mg. At that time, her BP was ≈ 74/34. She becamebradycardic and, within 1 minute, her pulse rate decreasedfrom 70 to 50 and finally 30. Ephedrine 15mg, glycopyrrolateand phenylephrine 100µg were administered, and her BPincreased to ≈ 148/80 and her HR to the 150s. She then beganreporting headache and left chest pain [times to reaction onsetnot stated].

The woman received esmolol and surgery was commenced.Subsequent monitoring revealed ST depression in leads II, IIIand AVF, and a second esmolol dose was administered; shealso received labetalol for BPs of up to ≈ 166/100, andmetoprolol. Her ST alterations improved with her increasingHR; her BP stabilised at 130s/80s and her HR at 100–110. At arecovery room after delivery, an ECG showed ST depression,asymmetric T-waves in leads II, III and AVF, and a 1mm STdepression in V2-V6. Her symptoms resolved and her vitalsigns remained stable. However, CK-MB and troponin werepositive, and she started receiving β-blockers and aspirin.Over the next 24–36 hours, her troponin level decreased; STchanges had resolved 2 hours post surgery. In the morning,echocardiography revealed hypokinesis in the basilar posteriorand basilar anterior septa, and in the basilar anterolateral wall.Her left ventricular ejection fraction was 50% and her leftatrium was dilated with moderate to severe mitralregurgitation. She was admitted to a cardiac care unit, where2+ mitral regurgitation was diagnosed. She was dyspnoeic andfurosemide was administered for pulmonary oedema.Hypokinesia had almost resolved on repeat echocardiography48 hours post surgery, and mitral regurgitation had improved.Sympathomimetic-induced coronary vasospasms and Tako-Tsubo cardiomyopathy were suspected. Her symptomssubsequently resolved, and resolution of wall motion changeswas expected.Patel S, et al. Sympathomimetic induced coronary artery vasospasm: Tako Tsubocardiomyopathy. Anesthesia and Analgesia 106 (Suppl.): abstr. A-66, No. 5, May2008. - USA 801121366

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Reactions 9 Aug 2008 No. 12140114-9954/10/1214-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved