A Case of Wide QRS Tachycardia After the Local Administration of Epinephrine to Reduce Bleeding During General Anesthesia

Abstract

We report a case of wide QRS tachycardia or ventricular tachycardia with a pulse after the administration of epinephrine under general anesthesia. After induction and achieving a sufficiently deep plane of general anesthesia, gauze soaked in a 1:100,000 epinephrine solution was applied to the patient's nasal mucosa and 1% lidocaine with 1:100,000 epinephrine was administered via intraoral infiltration. Several minutes after the start of surgery, the patient's blood pressure and heart rate suddenly increased and a wide QRS tachycardia was observed on the electrocardiogram, which then reverted to a normal sinus rhythm. According to the past reports, similar arrhythmias have occurred after administration of epinephrine in the head and neck. These findings suggest that anesthesia providers must be aware of the risks associated with epinephrine and local anesthetic use, particularly in the head and neck region.

CASE REPORT

This case report focuses on a 77-year-old female (height, 154 cm; weight, 41.5 kg; body mass index, 17.4 kg/m²) who underwent left partial maxillectomy for a malignant gingival tumor diagnosed as squamous cell carcinoma. The patient had previously been diagnosed with suspected angina 30 years prior although no detailed cardiac examination was performed, and she denied any history of chest pain since. No other systemic illnesses were reported, and preoperative laboratory findings of the patient were normal. A normal sinus rhythm was observed on the patient's electrocardiogram (ECG).

In the operating room, the patient's initial arterial blood pressure (ABP) via noninvasive blood pressure cuff and heart rate (HR) were 141/56 mm Hg and 81 bpm, respectively. General anesthesia was induced using fentanyl 50 μg, propofol 60 mg, and rocuronium 40 mg. The patient was nasally intubated, and an invasive arterial catheter was placed in the right radial artery. Anesthesia was maintained using sevoflurane 1.2% with oxygen 1 L/min and air 5 L/min plus a continuous infusion of remifentanil (0.1–0.2 μg/kg/min). Prior to the start of the surgical procedure, gauze soaked in a solution containing saline and 1:100,000 epinephrine (saline 100 mL + 1:1000 epinephrine 1 mL) was applied to the patient's nasal mucosa to minimize surgical bleeding from the nasal cavity. After confirming a negative aspiration, the surgeon then injected 10 mL of 1% lidocaine containing 1:100,000 epinephrine (total dose: lidocaine 100 mg and epinephrine 0.1 mg) into the left maxillary gingival mucosa via local infiltration. Approximately 7 minutes after placement of the epinephrine-soaked gauze and 2 minutes after injecting the local anesthetic, fentanyl 50 μg was administered intravenously for intraoperative analgesia, and the surgery was started. The patient's ABP per the right radial arterial line and HR were 126/78 mm Hg and 78 bpm at the start of surgery. However, 3 minutes after starting surgery, her ABP and HR suddenly increased to 187/76 mm Hg and 123 bpm, respectively, and the ECG showed a wide QRS complex tachycardia that was diagnosed as ventricular tachycardia with a pulse (Figure 1) as established by the continued presence of pulse oximeter and ABG waveforms. The surgery was interrupted to remove the epinephrine-soaked gauze and prepare the patient for use of a defibrillator in the event her cardiovascular status further deteriorated. The episode of ventricular tachycardia with a pulse persisted intermittently for 22 seconds. Thereafter, the patient spontaneously recovered to a normal sinus rhythm with a gradual decrease in ABP (100–120/45–60 mm Hg) and HR (80–90 bpm) coincident with adequate depth of anesthesia, and the surgery was resumed with no further abnormalities observed.

Figure 1.

Transient (∼22 seconds) ventricular tachycardia with a pulse. Electrocardiogram (leads II, V5, aVR), arterial blood pressure, and pulse oximetry waveforms during the wide QRS tachycardia event.

DISCUSSION

Previous studies have reported epinephrine-induced arrhythmias for surgeries involving the head and neck region under general anesthesia using sevoflurane or desflurane even though these agents are less likely to cause an arrhythmia compared with other inhalational anesthetics like halothane.^1–4 This is thought to be attributed to rapid absorption of epinephrine due to the presence of abundant blood flow in this region.¹ The wide QRS tachycardia or ventricular tachycardia with a pulse observed in the current case was presumed to be caused by a large amount of epinephrine entering the blood from 2 potential sources. Although an accidental intravascular injection could have occurred during injection of local anesthetic, it was deemed unlikely due to the timing of the wide QRS tachycardia onset relative to the injection.¹ Instead it was felt that the epinephrine dose delivered by the gauze was likely excessive as the exact amount contained in the gauze and ultimately absorbed through the patient's nasal mucosa was unknown. Administration of epinephrine requires care and attention to all potential sources of uptake to prevent inadvertent overdose.

The patient was referred for detailed cardiovascular examination postoperatively due to previous reports of healthy patients developing ventricular tachycardia after administration of epinephrine to the nasal mucosa who were later diagnosed with variant angina.^2,3 Unfortunately, the patient in this case decided against pursuing a referral and evaluation with cardiology.

CONCLUSION

Wide QRS tachycardia or ventricular tachycardia with a pulse was transiently observed in a patient under general anesthesia following topical nasal mucosal application of epinephrine-soaked gauze and intraoral infiltration of lidocaine with epinephrine for local anesthesia. Anesthesia providers must be aware of the risks associated with epinephrine and local anesthetic use, particularly in the head and neck region, and consider all potential sources for epinephrine uptake.

This research was originally published in the Journal of the Japanese Dental Society of Anesthesiology. 2020;48:63–65.