pulmonary edema in hypertensive crisis

[KidDoc29]

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I am a PGY-3 Pediactric resident going into Critical Care/Anesthesia combined fellowship. I serve on our hospital's pediatric/neonatal transport team and had a case yesterday that I wanted to share.
15 yr boy with old PE tubes and chronic suppurative otitis. Private hospital ENT performs tympanoplasty to close the hole, and gives (locally) 10 cc 1:10000 epi intraoperatively. SBP climbs from 120s to 230 instantly, with tachycardia to 160s, clearly intravascular injection. Anesthesiologist pushes 10 mg Labetolol; pressures drop to 90/40s over 20 min. Pt taken to PACU, tachypneic, dyspneic and having frothy hemoptysis. CXR with diffuse bilateral haziness. All told, received 2.5 L LR perioperatively. On our arrival, sitting upright, well-saturated in 6 L O2, which we were able to wean to 4. After 40 mg Lasix, weaned to 2 L and now feeling quite better.
My question regards the pathophysiology. Was this a patient who was relatively volume expanded from the IVFs, whose exogenous cathecolamine bolus made him systemically hypertensive; and then the beta blockade led to the pulmonary edema? Or could the hypertension in itself lead to the edema from changing starling forces? I know this probably is straightforward; I just couldn't get my head around it yesterday. Any insights appreciated.

 

[The_Sensei]

I am a PGY-3 Pediactric resident going into Critical Care/Anesthesia combined fellowship. I serve on our hospital's pediatric/neonatal transport team and had a case yesterday that I wanted to share.
15 yr boy with old PE tubes and chronic suppurative otitis. Private hospital ENT performs tympanoplasty to close the hole, and gives (locally) 10 cc 1:10000 epi intraoperatively. SBP climbs from 120s to 230 instantly, with tachycardia to 160s, clearly intravascular injection. Anesthesiologist pushes 10 mg Labetolol; pressures drop to 90/40s over 20 min. Pt taken to PACU, tachypneic, dyspneic and having frothy hemoptysis. CXR with diffuse bilateral haziness. All told, received 2.5 L LR perioperatively. On our arrival, sitting upright, well-saturated in 6 L O2, which we were able to wean to 4. After 40 mg Lasix, weaned to 2 L and now feeling quite better.
My question regards the pathophysiology. Was this a patient who was relatively volume expanded from the IVFs, whose exogenous cathecolamine bolus made him systemically hypertensive; and then the beta blockade led to the pulmonary edema? Or could the hypertension in itself lead to the edema from changing starling forces? I know this probably is straightforward; I just couldn't get my head around it yesterday. Any insights appreciated.

Classic error........giving a beta blocker in this scenario and having unopposed alpha stimulation.

 

[ecCA1]

"unopposed alpha stimulation"

Granted it's a 7:1 ratio of beta:alpha, but labetolol does provide for some alpha blockade.

 

[Gator05]

Labetolol not the worst drug to give here, but probably not the best.

Hydralazine or nitro would have been better. Heck, I probably would have reached for the propofol since it would have been the most readily available.

Without knowing too much more, and being only a CA-1, I would have thought a 15 y/o's ventricle to be compliant enough to handle a BP in the 200's for a short amount of time.

Also, was the hemoptysis noted intra-op? If solely noted post-op, you'd also have to consider NPPE on top of all of this.

Look forward to hearing from the more experienced folks.

 

[ecCA1]

" probably would have reached for the propofol since it would have been the most readily available."

Not to mention the fact that the labetolol takes a while to kick in.

Fentanyl or propofol would be the easiest for ME to access, as hydral and nitro are not in the room. However, nitro would work really well, as hydral takes a bit of time to work, too.

 

[Noyac]

First of all, the epi won't last long and as Gator said, the 15 yr old heart can tolerate it, as well as his cerebral vasculature. So the risk is probably minimal.
Now, to give labetolol, which will stick around for some time and take a few minutes to act is crazy. Its the last thing I would have given. I would have gone for the propofol as well, Gator. NTG would be a good choice also, but who has that available for this kind of case?
The Pulm. edema, is tricky to me. This kid should not have had that much PE in this case with his healty heart. It makes me think he may have had some instance of glottic closure leading to negative pressure pulmonary edema. Anyone that gives labetolol for intravascular epi wouldn't surprise me if they also caused some airway incident. I guess it is possible that the high pressure from the epi and the slowed HR along with the decreased contactility caused by the labetolol could have led to the PE.

 

[KidDoc29]

Thanks for the info everyone. I wasn't necessarily wondering what people would have done to lower the BP (although I agree labetolol wouldn't be 1st line choice). I was more curious as to what the origin of the pulm edema might have been in an otherwise healthy kid. Related to the hypertension itself? NPPE? Consequence of the beta blockade? Something else?

 

[militarymd]

IV injections of epi alone CAN cause "flash" pulmonary edema. There are many case reports, and I have personally seen this.

year 1997

Location: Guanatamo Bay cuba Naval Hospital.

Circumstances:

Young ASA 1 undergoing knee arthroscopy under spinal. The CRNA was doing the case, and I was else where. CRNAs have independent practice in the Navy. Spinal goes high. Patient becomes bradycardic and hypotension and unresponsive.

CRNA gives epi...dose unsure but less than 0.5 mg.....hard to tell when you are giving epi with concentration of 1 mg/ml without dilution.

Patient becomes hypertensive and tachycardic.......I enter the room at this point. I give NTG .......one of the recommended therapies, btw..and nothing else.

10 minutes later....pink frothy sputum...hypoxia...and crappy CXR....total LR received is less than 1 liter in a 80 kg plus guy.

 

[dhb]

IV injections of epi alone CAN cause "flash" pulmonary edema.

Can this happen with sub-cutaneous injection too?

 

[militarymd]

Can this happen with sub-cutaneous injection too?

yes