thoughts on this case

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furfur

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47 y.o. o/w healthy for tympanoplasty s/p rupture from fall. GETA. Uneventful intubation. 1MAC sevo on board w/ 100mcg fentanyl given during induction 10 minutes ago. surgeons give 2cc of 2% lido w/ 1:10,000 epi and then make incision. Preincision vitals: 95/50, 76, 100%. Post-incision vitals: 255/130, 78, 100%. Asked surgeons to stop and gave 10cc propofol, 100mcg fentanyl, gas up to 2MAC. next BP: 230/120. another 10cc propofol, 50 esmolol and 2.5MAC. BP finally comes under 200. Thoughts? do you proceed w/ the case?
 
1. IV epi by surgeon. should have had more tachycardia.
2. syringe swap - you gave neo or vasopressin unintentionally
3. cuff malfunction
 
furfur said:
47 y.o. o/w healthy for tympanoplasty s/p rupture from fall. GETA. Uneventful intubation. 1MAC sevo on board w/ 100mcg fentanyl given during induction 10 minutes ago. surgeons give 2cc of 2% lido w/ 1:10,000 epi and then make incision. Preincision vitals: 95/50, 76, 100%. Post-incision vitals: 255/130, 78, 100%. Asked surgeons to stop and gave 10cc propofol, 100mcg fentanyl, gas up to 2MAC. next BP: 230/120. another 10cc propofol, 50 esmolol and 2.5MAC. BP finally comes under 200. Thoughts? do you proceed w/ the case?
Click to expand...

2 cc of 1:10,000 epi is 200 mcg. Maybe he got a bit of that lidocaine/epi mix intravascular? Doesn't fit with the HR of 78 but that'd be my first guess. I'd proceed if he was back at baseline a couple minutes later.
 
I'd say its the epi, similar incident happend to me during a total hip b/c we have a surgeon who likes to inject tons of local with epi and some of it gets absorbed intravascularly. Slam him with propofol to control the bp, wait a few mins
 
I had a similar experience during a transphenoidal resection of pit. mass. After the ENT surgeon injected Epi to vasoconstrict the nasal mucosa, the A-line BP shot up >325mmHg systolically. It came down rather quickly, as we pushed almost 1 mg of Nicardipene and some labetalol, but it scared the piss out of me when it happened.
 
Is the patient on a beta blocker? unopposed alpha from epi? MAOI's or SSRI's? H/O drug abuse?

What is the temp, and CO2 doing? Thyroid OK....

Rule out the above... 99.9% sure I would continue the case and treat appropriately.
 
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