Distributive shock post SCS?

[Beeftenderloin]

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Had this weird case recently. I’m still at a loss. Any insight would be great.

60s M, HTN, BPH, chronic cervicalgia coming from home for phase II (permanent) cervical SCS implant. MAC anesthesia w/ 2mg midaz and propofol. Entered epidural space around T1-2, leads threaded up to C2. BP steadily drifted down throughout procedure but never got properly hypotensive during actual case.

Get paged from PACU shortly after CRNA dropped off that patient is hypotensive.

Patient still drowsy, not following commands, but moving everything and maintaining sats on 2LNC. BP 80s/40s, HR 90s. Patient got no fluids because of the shortage and it was an afternoon case so assumed he was just dry. Gave some Neo and told nurse to give 1L crystalloid. Paged back about 20mins later that patient isn’t responding to fluid and BP still low, checked that dressings were clean (they were) gave 50mg IM ephedrine and tell nurse to give rest of fluid. Paged back 10min later BP worse. 70s/40s, strangely not tachy, HR in ~70. Cycle cuff again at bedside and we’re 60s/30s. Now I’m concerned. Called for some more hands, so the next few things happened in tandem.

Quick POCUS showed hyperdynamic LV, mildly dilated but normally functioning RV, IVC with not plethoric with normal respirophasic variation. Normal upright CXR. EKG NSR. Art line placed and correlating with cuff. Levo started. CBC, CMP, ABG, trop, lactate sent. Patient saying their name and following commands by now. Stat formal echo agreed with above and was otherwise unremarkable. Labs very unremarkable, just mild respiratory acidosis on ABG.

Patient ended up going to ICU on 15mcg of levo which was slowly weaned to off by POD1 afternoon then discharged POD2. No additional work-up from ICU team.

Anyone ever see/hear of anything like this before?

 

[DocMcCoy]

Had this weird case recently. I’m still at a loss. Any insight would be great.

60s M, HTN, BPH, chronic cervicalgia coming from home for phase II (permanent) cervical SCS implant. MAC anesthesia w/ 2mg midaz and propofol. Entered epidural space around T1-2, leads threaded up to C2. BP steadily drifted down throughout procedure but never got properly hypotensive during actual case.

Get paged from PACU shortly after CRNA dropped off that patient is hypotensive.

Patient still drowsy, not following commands, but moving everything and maintaining sats on 2LNC. BP 80s/40s, HR 90s. Patient got no fluids because of the shortage and it was an afternoon case so assumed he was just dry. Gave some Neo and told nurse to give 1L crystalloid. Paged back about 20mins later that patient isn’t responding to fluid and BP still low, checked that dressings were clean (they were) gave 50mg IM ephedrine and tell nurse to give rest of fluid. Paged back 10min later BP worse. 70s/40s, strangely not tachy, HR in ~70. Cycle cuff again at bedside and we’re 60s/30s. Now I’m concerned. Called for some more hands, so the next few things happened in tandem.

Quick POCUS showed hyperdynamic LV, mildly dilated but normally functioning RV, IVC with not plethoric with normal respirophasic variation. Normal upright CXR. EKG NSR. Art line placed and correlating with cuff. Levo started. CBC, CMP, ABG, trop, lactate sent. Patient saying their name and following commands by now. Stat formal echo agreed with above and was otherwise unremarkable. Labs very unremarkable, just mild respiratory acidosis on ABG.

Patient ended up going to ICU on 15mcg of levo which was slowly weaned to off by POD1 afternoon then discharged POD2. No additional work-up from ICU team.

Anyone ever see/hear of anything like this before?

Abx given?

 

[Beeftenderloin]

Abx given?

Ancef given. No rash. Was never tachy. Not on BB. Did not listen for wheezing. Hypotension was 2-3 hours after atbx admin. Didn’t send a tryptase because it didn’t seem like anaphylaxis. I suppose its possible, but aside from hypotension there were no other signs to suggest it.

 

[teacher2md]

Was local anesthetic injected into the field; potentially intrathecal or subdural?

 

[Tramadeezy]

LOR with local? Ive seen saline get switched for 0.25% Bupi

 

[Maverikk]

Data points:
-hypotension
-hyperdynamic LV (in the setting of chronic hypertension)
-normal labs (I'm assuming no fever and lactate should've risen if true malperfusion)
-minimal anesthesia

What was the patient's pre-op BP? Was this a late in the day case?
With no signs of end organ dysfunction/AMS (patient following commands) or lactate I wouldn't call this shock, the only data point you have is a low BP

 

[chessknt]

Data points:
-hypotension
-hyperdynamic LV (in the setting of chronic hypertension)
-normal labs (I'm assuming no fever and lactate should've risen if true malperfusion)
-minimal anesthesia

What was the patient's pre-op BP? Was this a late in the day case?
With no signs of end organ dysfunction/AMS (patient following commands) or lactate I wouldn't call this shock, the only data point you have is a low BP

eh not so certain of that--CNS dysfunction sounds like it was present at least while he was hypoperfusing. Quick intervention since PACU isnt going to let him sit long with the MAP in the 40s is going to prevent AKI/lactate from rising because he isnt sitting hypotensive at home unmonitored for 8 hours.

Agree with LAST, not sure if mild spinal shock is a known complication from this either but might also explain it. Massive bacterial translocation with SIRS could be another consideration but would be hard to source. Adrenal crisis possible if he was given steroids. Quick turnaround <24h makes it seem related to a drug given though.

 

[nimbus]

Fortunately this happened in a hospital so proper care and support could be given. I’ve only done SCS at surgicenters, never at the hospital.

 

[Beeftenderloin]

Was local anesthetic injected into the field; potentially intrathecal or subdural?

LOR with local? Ive seen saline get switched for 0.25% Bupi

Yes local was injected. I don’t recall specifically what/how much. LOR with “saline” so I guess epi/sub-dural injection of local is possible with a drug mix-up. It did seem to be behaving a lot like a sympathectomy. He was moving everything, but I guess if it was just a few mls of 0.25% bupi it’s possible he got a sympathectomy and motor was spared. But even then, a single shot of dilute bupi in the epidural space shouldn’t result in a profound vasopressor requirement lasting nearly 24hrs.

 

[abolt18]

LOR with local? Ive seen saline get switched for 0.25% Bupi

This is exactly where my mind went.

 

[Beeftenderloin]

Data points:
-hypotension
-hyperdynamic LV (in the setting of chronic hypertension)
-normal labs (I'm assuming no fever and lactate should've risen if true malperfusion)
-minimal anesthesia

What was the patient's pre-op BP? Was this a late in the day case?
With no signs of end organ dysfunction/AMS (patient following commands) or lactate I wouldn't call this shock, the only data point you have is a low BP

Normotensive in pre-op, 130s/60s. He had a map less than 50 for a single digit number of minutes in PACU. They never had the opportunity to start making lactate. Patient was obtunded for what seemed like longer than he should have been given the anesthetic he received and he only started following commands after 5-10mins with a normal BP.

 

[DesiredMemberName?]

HR inappropriately low given hypotension. Pt not on BB. Id be thinking neurogenic etiology in this context.

Maybe drug related.. maybe they caused some minor trauma that improved over the following 24hrs.

 

[Radetzky]

Hard to imagine you could cause a high thoracic / cervical spinal without some motor/respiratory insufficiency. And you get ECG changes with LAST by the time you get hypotensive.

Maybe chalk it up to POND syndrome?
Post Operative Nor-epinephrine Deficiency

 

[Timeoutofmind]

That’s why I started drawing up all of my own drugs for pain procedures after a few years in this game…

 

[sloh]

.

 

[PainDrain]

Was the SCS turned on at the time hypotension occurred?

 

[lobelsteve]

Never heard of LOR with anything but air for SCS. Im 20 years in and use only lateral fluoroscopy to confirm posterior epidural lead/needle placement. No LOR, Lead in needle after engaging ligament in AP.

 

[Hoya11]

Had this weird case recently. I’m still at a loss. Any insight would be great.

60s M, HTN, BPH, chronic cervicalgia coming from home for phase II (permanent) cervical SCS implant. MAC anesthesia w/ 2mg midaz and propofol. Entered epidural space around T1-2, leads threaded up to C2. BP steadily drifted down throughout procedure but never got properly hypotensive during actual case.

Get paged from PACU shortly after CRNA dropped off that patient is hypotensive.

Patient still drowsy, not following commands, but moving everything and maintaining sats on 2LNC. BP 80s/40s, HR 90s. Patient got no fluids because of the shortage and it was an afternoon case so assumed he was just dry. Gave some Neo and told nurse to give 1L crystalloid. Paged back about 20mins later that patient isn’t responding to fluid and BP still low, checked that dressings were clean (they were) gave 50mg IM ephedrine and tell nurse to give rest of fluid. Paged back 10min later BP worse. 70s/40s, strangely not tachy, HR in ~70. Cycle cuff again at bedside and we’re 60s/30s. Now I’m concerned. Called for some more hands, so the next few things happened in tandem.

Quick POCUS showed hyperdynamic LV, mildly dilated but normally functioning RV, IVC with not plethoric with normal respirophasic variation. Normal upright CXR. EKG NSR. Art line placed and correlating with cuff. Levo started. CBC, CMP, ABG, trop, lactate sent. Patient saying their name and following commands by now. Stat formal echo agreed with above and was otherwise unremarkable. Labs very unremarkable, just mild respiratory acidosis on ABG.

Patient ended up going to ICU on 15mcg of levo which was slowly weaned to off by POD1 afternoon then discharged POD2. No additional work-up from ICU team.

Anyone ever see/hear of anything like this before?

maybe a profound autonomic reaction to dural stretching during the lead placement, lots of high price real estate in the brain/cord from t2-c2 to mess with by putting a foreign body right on top of it, especially in a tight space, in a patient who was dry and no fluids

 

[HalO'Thane]

What blood pressure medications was he on? An ace inhibitor? I usually see bad hypotension in patients on ACEI with big induction doses of propofol and volatile agents, but if this was a sicker patient who was also dry, maybe you would also see it in a MAC.

I wouldn’t be convinced about LAST if he had no EKG changes. If it was spinal/neurogenic etiology, I agree with the other posters that you would probably see more motor changes.

The bradycardia sounds to me more like a vagal response to the evolving and profound hypotension more than anything else, especially if a follow up bedside cardiac ultrasound showed a hyperdynamic left ventricle once resuscitation started. In that situation where you think you have a low SVR state, I like giving vasopressin boluses.

The only other thing to consider would be giving solucortef. Stress dose steroids seem like voodoo to me half the time, but in this case it may not hurt. I also believe that you can sometimes only present with hypotension in a case of anaphylactic shock. If the blood pressure is low enough, you may not have enough perfusion to get erythematous.

 

[PpfSuxTube]

Vasoplegia nyd probably from wierd sympathectomy re procedure itself...
You did everything perfectly
Only other thing was swan for svr but I'm cardiac so swan answer for everything

 

[Tuohys&Bougies]

Seems hard to blame at T1-T2 a possible bupi epidural injection unless the person is slamming in 5cc of their solution after loss. I've given 1cc of lidocaine in cervical epidurals before and never had an issue, though to be fair I stopped doing that. Maybe cord compression from the epidural leads? Causing some sort of vagal response combined with hypovolemia?