Unusually large ephedrine-induced blood pressure increases due to cardiac sympathetic denervation supersensitivity in a patient with Parkinson’s disease

Shirai, Toru; Kitaura, Atsuhiro; Uehara, Keiji; Uchida, Tomohisa; Fuyuta, Masaki; Iwamoto, Tatushige; Hiramatsu, Kazuhiro; Nakao, Shinichi

doi:10.1186/s40981-018-0181-2

Cited by 5 publications

(5 citation statements)

References 11 publications

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“…In addition, the fact that only the blood pressure increased and the heart rate did not change significantly is unusual, which is similar to the findings observed in the patients with Parkinson disease. [9,13] Therefore, we speculated that in the present case, a severe intraoperative reduction in the sympathetic pathway activity to the heart may have caused transient hypersensitivity.…”

Section: Discussionmentioning

confidence: 81%

“…[8] To determine the reason for the abnormal reaction to ephedrine administration in the present case, we referred to reports of ephedrine adverse reactions in patients with Parkinson disease. [9][10][11] These reports indicated that cardiac sympathetic nerve denervation can occur in patients with Parkinson disease, resulting in excessive cardiovascular responses to sympathomimetic drugs; this condition is known as cardiac sympathetic denervation supersensitivity. Its mechanism of action could be explained by an absence of norepinephrine uptake or an increased density of β-adrenergic receptors in postsynaptic membranes.…”

Section: Discussionmentioning

confidence: 99%

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Severe blood pressure elevation following ephedrine administration during carotid endarterectomy under general anesthesia: A CARE-compliant case report

Kim

2023

Medicine

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Rationale: During carotid endarterectomy (CEA) surgery, blood pressure management is particularly important to prevent cerebrovascular and cardiac complications. Ephedrine is a commonly used vasopressor, however, we report the case of a patient with unusually severe blood pressure elevation following intravenous ephedrine administration during CEA.Patient concerns: A 72-year-old man diagnosed with right proximal internal carotid artery stenosis underwent CEA under general anesthesia. After declamping the common carotid artery, blood pressure rapidly increased by 125 mm Hg (from 90 to 215 mm Hg) after ephedrine (4 mg) was administered, but the heart rate was stable.Diagnoses: There was an ordinal increase in blood pressure after the same small dose of ephedrine was administered at the early stage of the surgery. And the surgical approach was difficult because he had a high location of carotid bifurcation and a prominent mandibular angle. Because of the anatomical proximity of the cervical sympathetic trunk to the carotid bifurcation and the particularly complicated surgical process in the present case, we postulate the reason for this adverse reaction as transient sympathetic denervation supersensitivity.Interventions: Perdipine (0.5 mg) was administered repeatedly to reduce blood pressure.Outcomes: After surgery, he was diagnosed with right hypoglossal nerve palsy, and no other abnormal signs were found. Conclusion:This case highlights the need for caution in the use of ephedrine, which is commonly used in CEA surgery, wherein blood pressure management is particularly important. Although it is a rare and unpredictable case, α-agonists are considered safer in situations where sympathetic supersensitivity is possible.

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Section: Discussionmentioning

confidence: 81%

Section: Discussionmentioning

confidence: 99%

Severe blood pressure elevation following ephedrine administration during carotid endarterectomy under general anesthesia: A CARE-compliant case report

Kim

2023

Medicine

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“…Cardiac consequences of DAN manifest as damage to the nerve fibers that innervate the heart and blood vessels, resulting in abnormalities in HR dynamics, increased risk of arrhythmias, and potential for SCD 41 , 44 . Likewise, clinical evidence suggests that patients with Parkinson’s disease may have supra-physiologic cardiovascular responses to adrenergic stimulation 45 , 46 , but detailed investigations of cardiac electrophysiological responses in these patients have not been performed. We previously showed that aged hearts have significantly decreased ventricular sympathetic nerve density, ventricular NE content, and reduced responsiveness to SNS 47 .…”

Section: Discussionmentioning

confidence: 99%

Adrenergic supersensitivity and impaired neural control of cardiac electrophysiology following regional cardiac sympathetic nerve loss

Tapa

Wang

Stuart

et al. 2020

Sci Rep

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Myocardial infarction (MI) can result in sympathetic nerve loss in the infarct region. However, the contribution of hypo-innervation to electrophysiological remodeling, independent from MI-induced ischemia and fibrosis, has not been comprehensively investigated. We present a novel mouse model of regional cardiac sympathetic hypo-innervation utilizing a targeted-toxin (dopamine beta-hydroxylase antibody conjugated to saporin, DBH-Sap), and measure resulting electrophysiological and Ca2+ handling dynamics. Five days post-surgery, sympathetic nerve density was reduced in the anterior left ventricular epicardium of DBH-Sap hearts compared to control. In Langendorff-perfused hearts, there were no differences in mean action potential duration (APD80) between groups; however, isoproterenol (ISO) significantly shortened APD80 in DBH-Sap but not control hearts, resulting in a significant increase in APD80 dispersion in the DBH-Sap group. ISO also produced spontaneous diastolic Ca2+ elevation in DBH-Sap but not control hearts. In innervated hearts, sympathetic nerve stimulation (SNS) increased heart rate to a lesser degree in DBH-Sap hearts compared to control. Additionally, SNS produced APD80 prolongation in the apex of control but not DBH-Sap hearts. These results suggest that hypo-innervated hearts have regional super-sensitivity to circulating adrenergic stimulation (ISO), while having blunted responses to SNS, providing important insight into the mechanisms of arrhythmogenesis following sympathetic nerve loss.

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“…We previously reported a case of unusually strong responses to ephedrine in a patient with PD under general anesthesia, which we thought was due to the sympathetic nerve denervation supersensitivity, because the patient’s sympathetic nerves to the heart were completely denervated [6]. However, to the best of our knowledge, there have been few other clinical reports on denervation supersensitivity.…”

Section: Discussionmentioning

confidence: 99%

“…This phenomenon is often overlooked because it can only be detected when sympathomimetic agents are administered. However, anesthesiologists should be aware of this phenomenon because it can cause dangerous hemodynamic changes [4–6]. Here, we present a case of ephedrine-induced increases in blood pressure and heart rate suspected to be due to denervation supersensitivity in a patient with PD.…”

Section: Introductionmentioning

confidence: 98%

Ephedrine-Induced Increases in Blood Pressure and Heart Rate Due to Suspected Cardiac Sympathetic Denervation Supersensitivity in a Patient with Parkinson’s Disease Under Spinal Anesthesia

2019

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Patient: Female, 60 Final Diagnosis: Parkinson disease Symptoms: Unusual reaction to ephedrine Medication: Ephedrine Clinical Procedure: — Specialty: Anesthesiology Objective: Rare disease Background: Denervation supersensitivity to sympathomimetic drugs has been noted in patients with Parkinson’s disease (PD) whose cardiac sympathetic nerves are denervated. This phenomenon is not as well recognized as other complications of PD patients, but anesthesiologists should be aware of it because sympathomimetic drugs can sometimes be dangerous to these patients. Case Report: A 60-year-old woman was scheduled for total hip joint replacement under combined spinal-epidural anesthesia and sedation. She had been diagnosed as PD (stage 4 on the Hoehn and Yahr scale) with a history of orthostatic hypotension. Her 123 I-metaiodobenzylguanidine (MIBG) scintigraphy revealed marked reduction of 123 I-MIBG accumulation in the heart. In the operating room, we placed an epidural catheter through the Th12–L1 space, and spinal anesthesia (2.6 mL of 0.5% normobaric bupivacaine) was administered. During the surgery, we infused propofol at 100 mg·hr −1 for sedation. When 4 mg of ephedrine was administered intravenously because of marked decrease in patient’s blood pressure, we observed unexpectedly large increases in the systolic blood pressure, from 78 mmHg to 168 mmHg, and the heart rate increased from 52 to 84 beats per minute (bpm). This phenomenon recurred each time 4 mg of ephedrine was administered. Conclusions: We report a case in which ephedrine induced unexpectedly large increases in blood pressure and heart rate in a patient who suffered from PD with severe cardiac sympathetic nerve denervation. We speculate that this phenomenon was caused by denervation supersensitivity of the patient’s heart.

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Unusually large ephedrine-induced blood pressure increases due to cardiac sympathetic denervation supersensitivity in a patient with Parkinson’s disease

Cited by 5 publications

References 11 publications

Severe blood pressure elevation following ephedrine administration during carotid endarterectomy under general anesthesia: A CARE-compliant case report

Severe blood pressure elevation following ephedrine administration during carotid endarterectomy under general anesthesia: A CARE-compliant case report

Adrenergic supersensitivity and impaired neural control of cardiac electrophysiology following regional cardiac sympathetic nerve loss

Ephedrine-Induced Increases in Blood Pressure and Heart Rate Due to Suspected Cardiac Sympathetic Denervation Supersensitivity in a Patient with Parkinson’s Disease Under Spinal Anesthesia

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