Hemodynamics after endoscopic submucosal injection of epinephrine in patients with nonvariceal upper gastrointestinal bleeding: a matter of concern

Abstract

We report about detailed hemodynamic changes and one major cardiac complication occurring after submucosal injection of epinephrine (1 : 10 000) for management of upper gastrointestinal bleeding in a series of four consecutive patients. Cardiac contractility and afterload, determined by the cardiac index and the systemic vascular resistence index (SVRI), were assessed by transpulmonary thermodilution using the Pulse Contour Cardiac Output monitoring system (PiCCO; Pulsion Medical Systems, Munich, Germany), and the mean arterial pressure and heart rate were recorded. We observed a distinct rise in both mean arterial pressure and heart rate, and this effect was pronounced in the three patients with esophageal lesions. The increase in the mean arterial pressure was caused by an elevation of the cardiac index in two patients, a rise in both cardiac index and SVRI in one patient, and a rise in the SVRI only in the fourth patient. One patient, who had received 30 ml epinephrine for treatment of a bleeding Mallory-Weiss tear, developed an acute myocardial infarction during the postprocedural follow-up period. In conclusion, submucosal injection of epinephrine may cause significant hemodynamic changes that can potentially lead to adverse cardiac events. Close cardiac monitoring during and after submucosal application of epinephrine therefore seems a prudent precaution. In the treatment of esophageal lesions, the total amount of epinephrine injected should be carefully titrated, so that the lowest possible volume that achieves adequate hemostasis is used.

Post-Sphincterotomy Bleeding: Who, What, When, and How

“…In this study, initial hemostasis was reached in 96% and recurrent bleeding was observed only in 4%. One should be cautious when using epinephrine in patients with underlying coronary artery disease or cardiac arrhythmias, since sys- temic absorption may occur and result in myocardial events (55).…”

Endoscopic Hemostasis With Metallic Hemoclips for Iatrogenic Mallory‐weiss Tear Caused by Endoscopic Examination

“…Several hemostasis procedures applied to MWT include endoscopic band ligation, 15–18 endoscopic injection therapy, 17,19–25 endoscopic electrocoagulation 15,26,27 and selective arterial embolization 28,29 . Previous reports indicated the efficacy of hemoclips for MWT 19,20,30,31 .…”

“…8,9 Most patients with MWT do not require endoscopic hemostasis and blood transfusion, [2][3][4][5] but several reports have indicated that patients with wide tears on the gastroesophageal mucosa suffered from massive bleeding and required endoscopic hemostasis. [11][12][13][14] Several hemostasis procedures applied to MWT include endoscopic band ligation, [15][16][17][18] endoscopic injection therapy, 17,[19][20][21][22][23][24][25] endoscopic electrocoagulation 15,26,27 and selective arterial embolization. 28,29 Previous reports indicated the efficacy of hemoclips for MWT.…”

Endoscopic mucosal resection

“…40 Submucosal injection of epinephrine potentially can result in systemic effects such as severe hypertension, ventricular tachycardia, and intestinal ischemia; however, case reports regarding these complications are rare and result from procedures in which the goal of therapy was hemostasis rather than EMR and during which higher concentrations of epinephrine (1:10,000) were used. [41][42][43] Staining dye (ie, diluted indigo carmine or methylene blue) is frequently added to the injection solution to facilitate identification of the lateral and deep margins of the target lesion before and during the resection process. The staining dye may also improve recognition of muscularis propria injury and intraprocedural perforation.…”