Cardiovascular collapse during anesthesia in a patient with preoperatively discontinued chronic MAO inhibitor therapy.
We describe a patient in whom long-term monoamine oxidase (MAO) inhibitor therapy was discontinued 20 days before surgery with general anesthesia. This patient developed severe perioperative hypotension after administration of 10 mg of bupivacaine through an epidural catheter, which was corrected only after potent vasopressor therapy. We attribute this hemodynamic instability to attenuation of this patient's sympathetic tone based on several mechanisms: (1) residual effect of long-term administration of MAO inhibitor that caused a decrease in the number of beta-adrenergic receptors (adrenergic subsensitivity due to receptor down-regulation), (2) recovered MAO activity causing effective degradation of sympathetic amines, and (3) combined attenuating effects of general and epidural anesthesia on sympathetic tone.
Sprung
J
J
Department of General Anesthesiology, Cleveland Clinic Foundation, OH 44195, USA.
Distel
D
D
Grass
J
J
Bloomfield
E L
EL
Lavery
I C
IC
D000368:Aged; D015360:Analgesia, Epidural / Q000009:adverse effects; D000768:Anesthesia, General / Q000009:adverse effects*; D000779:Anesthetics, Local / Q000009:adverse effects; D002045:Bupivacaine / Q000009:adverse effects; D003082:Colectomy; D015536:Down-Regulation / Q000187:drug effects; D005260:Female; D006801:Humans; D007022:Hypotension / Q000188:drug therapy / Q000209:etiology; D007431:Intraoperative Complications; D008996:Monoamine Oxidase Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use*; D011300:Preoperative Care; D011943:Receptors, Adrenergic, beta / Q000032:analysis / Q000187:drug effects; D012004:Rectal Neoplasms / Q000601:surgery; D012769:Shock / Q000188:drug therapy / Q000209:etiology*; D013564:Sympathetic Nervous System / Q000187:drug effects; D013566:Sympathomimetics / Q000378:metabolism; D014191:Tranylcypromine / Q000008:administration & dosage / Q000627:therapeutic use*; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
D000779:Anesthetics, Local; D008996:Monoamine Oxidase Inhibitors; D011943:Receptors, Adrenergic, beta; D013566:Sympathomimetics; D014662:Vasoconstrictor Agents; D014191:Tranylcypromine; D002045:Bupivacaine