Severe blood pressure elevation following ephedrine administration during carotid endarterectomy under general anesthesia: A CARE-compliant case report.

RATIONALE: During carotid endarterectomy (CEA) surgery, blood pressure management is particularly important to prevent cerebrovascular and cardiac complications. Ephedrine is a commonly used vasopressor, however, we report the case of a patient with unusually severe blood pressure elevation following intravenous ephedrine administration during CEA. PATIENT CONCERNS: A 72-year-old man diagnosed with right proximal internal carotid artery stenosis underwent CEA under general anesthesia. After declamping the common carotid artery, blood pressure rapidly increased by 125 mm Hg (from 90 to 215 mm Hg) after ephedrine (4 mg) was administered, but the heart rate was stable. DIAGNOSES: There was an ordinal increase in blood pressure after the same small dose of ephedrine was administered at the early stage of the surgery. And the surgical approach was difficult because he had a high location of carotid bifurcation and a prominent mandibular angle. Because of the anatomical proximity of the cervical sympathetic trunk to the carotid bifurcation and the particularly complicated surgical process in the present case, we postulate the reason for this adverse reaction as transient sympathetic denervation supersensitivity. INTERVENTIONS: Perdipine (0.5 mg) was administered repeatedly to reduce blood pressure. OUTCOMES: After surgery, he was diagnosed with right hypoglossal nerve palsy, and no other abnormal signs were found. CONCLUSION: This case highlights the need for caution in the use of ephedrine, which is commonly used in CEA surgery, wherein blood pressure management is particularly important. Although it is a rare and unpredictable case, α-agonists are considered safer in situations where sympathetic supersensitivity is possible.

Anesthetic management for inhibiting sympathetic activation in an adolescent patient diagnosed with catecholaminergic polymorphic ventricular tachycardia and undergoing left cardiac sympathetic denervation: A case report.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a genetic disorder in which catecholamine release during exercise or emotional stress cause fatal tachyarrhythmias. In this paper, we discuss methods to minimize the sympathetic stimulation that can occur during the perioperative period in patients undergoing left cardiac sympathetic denervation to surgically treat CPVT.

Suspected Malignant Hyperthermia in a Brain-Dead Donor During Anesthesia for Organ Procurement Surgery: A Case Report.

We report an unusual case of highly suspected malignant hyperthermia after inducing anesthesia in a brain-dead 18-year-old male patient undergoing organ procurement surgery. The patient was administered desflurane (3 vol%) and rocuronium bromide (50 mg) to induce and maintain general anesthesia. He experienced hypercapnia and tachycardia within 5 minutes of anesthesia induction; however, his body temperature rapidly rose only after 15 minutes. The volatile anesthetic was discontinued, and dantrolene was administered at a low dose (1 mg/kg) to avert possible hepatotoxic effects on the donor liver. Fortunately, the clinical course of the brain-dead donor until the organs were harvested and the liver transplantation outcome of the recipient was favorable. A comprehensive understanding of the pathophysiology of brain death, organ transplantation, and malignant hyperthermia is essential to respond promptly and appropriately. Based on our experience, low-dose dantrolene may be clinically used in brain-dead donors while accounting for its potential hepatotoxic effects.

Sudden arrhythmia in the prone position during spinal surgery: A case report.

RATIONALE: The prone position is the most commonly required position during spinal surgery. Decreasing lumbar lordosis is necessary to facilitate the accessibility of the surgical field. And this can affect the hemodynamic circulation of the patients. The Jackson spine table is one of the most preferred methods, known to have minimal effects on cardiac function. PATIENT CONCERNS: We report a case of sudden arrhythmia that developed during the prone position using a Jackson spine table. It occurred 30 minutes after the positional change. DIAGNOSES: Arrhythmia showed bizarre P and QRS waves. Ectopic P, bundle branch block, or both was suspected. INTERVENTIONS: Because it was difficult to define the exact type or cause of this sudden arrhythmia and considering that other vital signs remained stable, we decided to keep close observation during the operation rather than applying uncertain antiarrhythmic medication. OUTCOMES: Arrhythmia spontaneously developed and subsided repeatedly. And it recovered to normal sinus rhythm immediately after the positional change to the supine position. Therefore, increased intrathoracic pressure caused by the prone position was highly suspected to be the cause of this event. LESSONS: Although the Jackson spine table is known to have the least effect on cardiac function, the patient experienced arrhythmia in our case. Hence, to achieve better clinical outcomes, an understanding of physiological alterations and possible complications caused by the prone position is necessary for earlier diagnosis and management.