Hazards of Epinephrine in Transsphenoidal Pituitary Surgery

Abstract

A 79-year-old woman with no history of myocardial ischemia presented with symptoms of pituitary apoplexy for which an urgent transsphenoidal resection of the pituitary gland was undertaken. The nasal passages were prepared with topical application of epinephrine followed by injection of what was presumed to be 1% lidocaine containing 10 microg/ml(-1) of epinephrine. After only 1.5 mL of the solution had been injected, she developed a hypertensive crisis, which was immediately treated. Postoperatively, she developed a myocardial infarction. The risks associated with the use of vasopressors are reviewed and suggestions for their safe use are presented.

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

“…Although the vasoconstrictive effect of oxymetazoline is not as powerful as some of these other agents, it has become one of the most commonly used given its favorable safety profile. [4][5][6] Cocaine has been associated with tachycardia, hypertension, and enhancement of the excitatory effects of epinephrine. 7,8 These side effects, coupled with its addictive potential, have led to a decline in the use of cocaine over the past 30 years.…”

Anesthesia and Intensive care implications for pituitary surgery: Recent trends and advancements

“…Patients on beta blockers can develop severe hypertension during the peri-operative period due to unopposed action of epinephrine on α-receptors. [32] Treatment to this complication consists of either administration of direct vasodilator or increasing the depth of anesthesia. Literary evidence cites the effective usage of opioids and the above mentioned drugs to attenuate the hypertensive response.…”

Anaesthesia for pituitary surgery

“…Prompt treatment with labetolol, alpha-antagonists (such as phentolamine), beta-blockers or vasodilators (such as nitroglycerin or sodium nitroprusside) is advocated. 21 Alternatively, deepening anaesthesia or bolusing a shortacting, potent opioid (such as alfentanil or remifentanil) is also effective. 2 Bilateral maxillary nerve blocks have also been described as a useful adjunct to general anaesthesia in suppressing the haemodynamic response to nasal infiltration with adrenaline-containing solutions, nasal dissection, and application of nasal speculum, but are rarely used in our region.…”