Cardiogenic shock following nasal septoplasty: a case report and review of the literature

Cardiovascular crisis after use of epinephrine: a case report and review of the literature

Diluted epinephrine is often locally used to provide hemostasis and improve visualization. However, rapid absorption or inadvertent intravascular injection of epinephrine can cause unexpected cardiovascular effects. A 28-year-old man was scheduled to undergo a nasal septoplasty. After local application of 0.01% epinephrine-soaked nasal pledgets and infiltration of 3 mL 0.001% epinephrine, the patient developed a severe hypertension of 205/126 mmHg, followed by ventricular tachycardia. Cardiac arrest ensued after intravenous injection of lidocaine and esmolol in an attempt to control ventricular arrhythmia. After successful resuscitation, the patient was transferred to the intensive care unit (ICU) and fully recovered in 5 days. While another two epinephrine-induced hypertension cases were treated smoothly without β-blockers. Although the plausible explanation of this precipitating event is the usage of β-blocker, we reviewed the previous published similar clinical reports and proposed other possible explanations and differential diagnosis. It is important to recognize this potential cardiovascular side-effect in patients administrated with topical and/or submucosal epinephrine. Drugs used to treat hypertension and/or arrhythmia needed to be appreciated.

Efficacy of Topical Epinephrine in Tympanoplasty

OBJECTIVES/HYPOTHESIS

To compare the hemostatic effects of commonly used concentrations of topical epinephrine in tympanoplasty.

STUDY DESIGN

Prospective, randomized, controlled clinical trial.

METHODS

Patients undergoing tympanoplasty were randomized to receive topical epinephrine at 1:1,000 or 1:10,000. With the investigators blinded, hemostasis was assessed with a modified Boezaart scale. Vasoconstriction was measured by laser Doppler. Blood pressure and pulse were tracked.

RESULTS

Thirty patients, 4 to 84 years old, were studied, with 15 patients per group. Boezaart scores dropped a mean of 67% and 62% with 1:1,000 and 1:10,000, respectively (P = .44). Capillary blood flow decreased a mean of 50.4% and 50.9% with 1:1,000 and 1:10,000, respectively (P = .95). The mean change in heart rate and mean arterial pressure after topical epinephrine exposure were -4.9 and -0.73 beats per minute (P = .15), and -0.60 and -0.73 mmHg (P = .96) for 1:1,000 and 1:10,000 respectively. No adverse events occurred in either group.

CONCLUSIONS

Topical epinephrine at 1:10,000 has hemostatic efficacy comparable to 1:1,000 in tympanoplasty. Although both concentrations appear safe, use of topical epinephrine 1:10,000 should be considered over 1:1,000 to minimize the potential for adverse events.

LEVEL OF EVIDENCE

2 Laryngoscope, 2021.

The effect of topical epinephrine 1:1000 with and without infiltration of 1% lidocaine with epinephrine 1:100,000 on endoscopic surgical field visualization: a double-blind randomized controlled study

BACKGROUND

The objective of this study is to determine whether the infiltration of 1% lidocaine with 1:100,000 epinephrine in addition to topical application of 1:1000 epinephrine significantly improves surgical field grading scale score over topical 1:1000 epinephrine alone.

METHODS

A prospective, double-blind, randomized, controlled study was performed of 40 patients undergoing bilateral endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Patients were enrolled and randomly assigned to receive infiltration with 1% lidocaine with 1:100,000 epinephrine on 1 side of the nasal cavity vs plain saline on the other side in preparation for ESS. Both groups received topical application of 1:1000 epinephrine. Surgical videos were recorded and Wormald surgical field grading scale was assigned by 2 blinded reviewers. The number of extra 1:1000 epinephrine pledgets used during the surgery, estimated blood loss, and surgical duration were also recorded.

RESULTS

There were no statistically significant differences in Wormald surgical field grading scale, number of extra pledgets used, or estimated blood loss between the nasal cavity side infiltrated with 1% lidocaine with 1:100,000 epinephrine in comparison to infiltration with saline. The side infiltrated with 1% lidocaine with 1:100,000 epinephrine had a reduced operative time compared to the side infiltrated with saline (p = 0.002). There were no differences in postoperative bleeding from questionnaire completed by patient at the first postoperative visit.

CONCLUSION

Addition of infiltration of 1% lidocaine with epinephrine 1:100,000 to topical application of epinephrine 1:1000 for preparation of ESS does not significantly improve surgical field of view compared to topical epinephrine alone.

Effect of Intranasal Vasoconstrictors on Blood Pressure: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Treatment for epistaxis includes application of intranasal vasoconstrictors. These medications have a precaution against use in patients with hypertension. Given that many patients who present with epistaxis are hypertensive, these warnings are commonly overridden by clinical necessity.

OBJECTIVE

Our aim was to determine the effects of intranasal vasoconstrictors on blood pressure.

METHODS

We conducted a single-center, randomized, double-blind, placebo-controlled trial from November 2014 through July 2016. Adult patients being discharged from the emergency department (ED) at Mayo Clinic (Rochester, Minnesota) were recruited. Patients were ineligible if they had a contraindication to study medications, had a history of hypertension, were currently taking antihypertensive or antidysrhythmic medications, or had nasal abnormalities, such as epistaxis. Subjects were randomized to one of four study arms (phenylephrine 0.25%; oxymetazoline 0.05%; lidocaine 1% with epinephrine 1:100,000; or bacteriostatic 0.9% sodium chloride [saline]). Blood pressure and heart rate were measured every 5 min for 30 min.

RESULTS

Sixty-eight patients were enrolled in the study; of these, 63 patients completed the study (oxymetazoline, n = 15; phenylephrine, n = 20; lidocaine with epinephrine, n = 11; saline, n = 17). We did not observe any significant differences in mean arterial pressure over time between phenylephrine and saline, oxymetazoline and saline, or lidocaine with epinephrine and saline. The mean greatest increases from baseline in mean arterial pressure, systolic and diastolic blood pressure, and heart rate for each treatment group were also not significantly different from the saline group.

CONCLUSIONS

Intranasal vasoconstrictors did not significantly increase blood pressure in patients without a history of hypertension. Our findings reinforce the practice of administering these medications to patients who present to the ED with epistaxis, regardless of high blood pressure.

Preoperative β-blockade and hypertension in the first hour of functional endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Local anesthetic with epinephrine is commonly injected into the nasal mucosa during functional endoscopic sinus surgery (FESS). Systemic absorption of epinephrine following local injection may occur, resulting in a mild sympathetic response. This study seeks to determine whether an exaggerated sympathetic response to epinephrine is demonstrated in patients undergoing FESS treated preoperatively with established pharmacologic beta (β) adrenoceptor blockade.

STUDY DESIGN

A retrospective analysis of adult patients undergoing FESS at a tertiary care university hospital.

METHODS

The primary outcome was the occurrence of an exaggerated hypertensive response within the first hour of surgical time defined by a relative increase (>20%) in the first measured intraoperative systolic blood pressure (SBP) prior to induction of anesthesia, or a single SBP value above 200 mm Hg. A mixed effects logistic regression model was developed to identify independent predictors of an exaggerated hypertensive response and describe the variance in the outcome attributable to the surgeon and anesthesiologist.

RESULTS

There were 2,051 patients identified. Independent predictors of an exaggerated intraoperative hypertensive event included: preoperative β-blocker use (adjusted odds ratio [AOR]: 3.33), female gender (AOR: 1.92), body mass index (AOR: 1.03), lower baseline SBP (AOR: 0.93), and advanced age (AOR: 1.03). The C statistic for the model was 0.8881.

CONCLUSIONS

Preoperative β-blocker use is an independent predictor of an exaggerated hypertensive response within the first hour of operative time. An exaggerated hypertensive effect should be anticipated in patients presenting for FESS with established pharmacologic β-blockade, and caution should be applied to use of epinephrine-containing solutions.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1496-1505, 2017.

Assessing the safety and efficacy of drugs used in preparing the nose for diagnostic and therapeutic procedures: a systematic review

BACKGROUND

Local anaesthetics and vasoconstrictors are essential for pain control and to aid intra-operative haemostasis in nasal procedures. They also improve access, and reduce discomfort when performing nasal endoscopy. There are no clear guidelines on preparing the nose despite evermore diagnostic and therapeutic procedures utilising the nose as a point of access.

OBJECTIVE OF REVIEW

This review aims to identify nasal preparations used in diagnostic and therapeutic nasal procedures and to examine their safety and efficacy.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

A search was carried out using PubMed, MEDLINE, Ovid EMBASE, the Cochrane library and references from the included articles.

EVALUATION METHOD

The inclusion criteria included: full-text English language articles with regard to nasal preparation for surgery. Case reports, systematic reviews, meta-analysis, double-blind placebo controlled randomised trials (RCTs) and case series were included.

RESULTS

A total of 53 articles were retrieved: 13 articles on nasal preparation for operative procedures, six on functional endoscopic sinus surgery and 22 on nasendoscopy as well as six case reports. Cocaine was the most widely used topical preparation for operative procedures but was associated with more side-effects; thus, topical tetracaine and levobupivacaine infiltration are alternatives with equivalent efficacy but reduced adverse effects. All articles reviewed for functional endoscopic sinus surgery used a mixture containing lidocaine, adrenaline or both. Flexible nasendoscopy causes minimal patient discomfort and preparation is only recommended in selected patients, in contrast to rigid nasendoscopy which requires preparation.

CONCLUSION

For operative procedures, such as septorhinoplasty, a single agent tetracaine or levobupivicaine provides an improved surgical field. In functional endoscopic sinus surgery, lidocaine-adrenaline preparations have resulted in significantly better surgical and patient outcomes. There is little evidence to support the routine use of pre-procedural nasal preparation for flexible nasendoscopy. Those undergoing rigid endoscopy conversely always require the use of a vasoconstrictor and local anaesthetic. Pre-procedure assessment of patients is recommended, with agents being reserved for those with low pain thresholds, high anxiety and small nasal apertures presenting resistance to the insertion of the endoscope.

Topical concentrated epinephrine (1:1000) does not cause acute cardiovascular changes during endoscopic sinus surgery

BACKGROUND

Topical epinephrine is used in endoscopic sinonasal surgery for local vasoconstriction. Potential for cardiovascular complications remains a concern for some due to the possibility of systemic absorption. Topical vs injected epinephrine was examined in a prospective analysis of perioperative cardiovascular effects, and in an audit of cardiovascular complications during endoscopic sinonasal surgery.

METHODS

A prospective cohort study of patients undergoing endoscopic sinonasal surgery was performed. Topical (1:1000) and injected (1:100,000) epinephrine were assessed. Cardiovascular outcomes of heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and electrocardiogram (ECG) changes were examined at baseline and minutely post-topical application (to 10 minutes) and postinjection (to 5 minutes). A retrospective assessment of cardiovascular events associated with a standardized regimen of topical (1:2000) and injected (1:100,000) epinephrine was performed.

RESULTS

Nineteen patents were assessed (43.42 ± 15.90 years, 47.4% female) in the prospective analysis. Post-topical epinephrine, no significant changes occurred in any cardiovascular parameter. However, following injected epinephrine, changes in HR (59.53 vs 64.11 bpm, p < 0.001), SBP (96.16 vs 102.95 mmHg, p = 0.015), DBP (56.53 vs 60.74 mmHg, p = 0.019), and MAP (69.74 vs 74.81 mmHg, p = 0.002) occurred. On repeated-measures analysis of variance (ANOVA) all parameters were significantly affected by injection. No ECG abnormalities were seen in either topical or injection phases. The retrospective analysis of 1260 cases identified 2 cases of cardiovascular complications (0.16%), both relating to injected epinephrine.

CONCLUSION

Combination topical (1:1000 to 1:2000) and injectable (1:100,000) epinephrine is safe for use in endoscopic sinonasal surgery. Injection resulted in the cardiovascular changes and accounted for the cardiovascular events reported.

Safety and efficacy of concentrated topical epinephrine use in endoscopic endonasal surgery

BACKGROUND

Effective topical decongestion is critical for the safe performance of endoscopic endonasal surgery (EES). Despite the vasoconstriction offered by topical concentrated (1:1000) epinephrine (CE), its use has not gained widespread acceptance because of concerns over systemic absorption and its effect on blood pressure and postoperative rebound epistaxis. The purpose of this study was to examine the physiological changes in blood pressure and rate of epistaxis with use of topical CE in a variety of endoscopic nasal procedures.

METHODS

EES procedures using inhalational anesthesia and topical CE performed on 1140 consecutive patients (14 patients under 18 years) between 2011 and 2014 were evaluated retrospectively. Demographic data, intraoperative hemodynamic parameters, and postoperative epistaxis rates were recorded.

RESULTS

The mean patient age was 45.8 years (range, 5-97 years). No intraoperative cardiovascular complications related to CE use were found. Four patients (0.35%) developed postoperative epistaxis requiring intervention. The mean estimated blood loss among patients undergoing bilateral sinus surgery, skull-base surgery, and orbital decompression was (mean ± SD) 61.7 ± 51.6 mL, 60.1 ± 115 mL, and 67.9 ± 42.2 mL, respectively. The maximum mean systolic blood pressure among these groups was 108.3 ± 28.3 mmHg, 111.9 ± 27.6 mmHg, and 95.1 ± 31.7 mmHg, respectively.

CONCLUSION

The use of topical CE is safe when performing endoscopic endonasal procedures. CE was not associated with any intraoperative complications. The profound intraoperative vasoconstriction does not confer a higher rate of postoperative rebound epistaxis.

Intraventricular haemorrhage as a complication of sub mucosal infiltration of adrenaline

Adrenaline infiltration is a widely used technique in head-neck and ENT surgeries to provide bloodless surgical field. However, use of adrenaline has been associated with hemodynamic changes which can be life threatening at times. Therefore, use of higher concentrations of adrenaline should be avoided and a close hemodynamic monitoring is required with use of other vasopressors. In the present case report, a young male died because of intraventricular bleeding caused by adrenaline infiltration during rhinoplasty.

Anaesthesia for Endoscopic Sinus Surgery: A Survey of Anaesthesiologists in Restructured Hospitals in Singapore

Introduction:

A cross-sectional survey of anaesthesiologists in Singapore's restructured hospitals was conducted to explore strategies employed to obtain a bloodless surgical field during endoscopic sinus surgery.

Methods:

All practicing anaesthesiologists in public institutions in Singapore were invited to answer an anonymous questionnaire. A point of contact per institution assisted in distribution and collection of questionnaire forms over a nine-month period.

Results:

A total of 114 anaesthesiologists completed the survey (response rate 60%). It was observed that 64.9% of respondents do not routinely employ controlled hypotension for endoscopic sinus surgery. Sixty-seven point five per cent chose general anaesthesia without nitrous oxide as the preferred anaesthetic technique for endoscopic sinus surgery. Forty-seven point four per cent opined that anaesthetic technique made no significant difference to outcomes in endoscopic sinus surgery. The most commonly used narcotics in endoscopic sinus surgery by the respondents were morphine (59.6%) and fentanyl (54.4%). However, where total intravenous anaesthesia was adopted, 86.0% of respondents opted to use remifentanil. The most commonly used class of antihypertensives for controlled hypotension was beta-blockers (66.7%). Factors limiting the use of total intravenous anaesthesia were also explored.

Conclusion:

This survey identifies variations from current evidence in the anaesthetic management of endoscopic sinus surgery among anaesthesiologists in Singapore's public institutions. The reasons behind these variations, which could include surgical preferences, financial, logistical, cultural, and educational factors, should be explored and any issues found addressed as necessary.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

BACKGROUND

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS

A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION

Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

Concentrated topical epinephrine is safe in endoscopic sinus surgery

BACKGROUND

The safety of topical epinephrine (1:1000 concentration) has recently been called into question. No objective data have been presented examining this issue.

METHODS

We retrospectively reviewed all cases of endoscopic sinus surgery performed by the senior authors at their respective institutions. Perioperative records were reviewed for use of topical 1:1000 epinephrine and for any intraoperative or postoperative complications related to its use.

RESULTS

During the study periods, 1998 cases of endoscopic sinus surgery were identified where topical 1:1000 epinephrine was used. Two complications were identified (0.1%), one at each institution. One patient suffered coronary artery vasospasm, attributed to the use of topical 1:1000 epinephrine during surgery. The other patient developed transient intraoperative hypertension immediately after inadvertent submucosal injection of concentrated epinephrine. This event was caused by an erroneous switch with the 1% lidocaine/1:100,000 solution. This error occurred early in the institution's experience with concentrated topical epinephrine. After implementation of additional preventative safeguards, no further errors or complications have occurred.

CONCLUSION

Concentrated epinephrine has the potential for complications when used during endoscopic sinus surgery. Nevertheless, with appropriate safeguards described in this study, its topical use is safe.

Managing the difficult airway in craniomaxillofacial trauma

Securing the airway in the patient with craniomaxillofacial trauma can be an extremely difficult challenge for health care practitioners. This article provides several approaches to airway management. Presented here are several options for securing the airway under a variety of conditions and scenarios.