Cardiogenic shock following nasal septoplasty: a case report and review of the literature.
OBJECTIVE
Nasal septoplasty is a surgical procedure offered to patients with chronic snoring secondary to nasal obstruction. We describe a case of cardiogenic shock following the administration of metoprolol to treat hypertension, (likely) induced by systemic absorption of topical epinephrine used during a routine nasal septoplasty.


METHODS
A 29-yr-old male, with no significant medical history, was scheduled for nasal septoplasty for mild nasal obstruction. Following routine anesthetic induction, cotton balls, soaked with epinephrine (1:1000), were applied to the nasal mucosa. The patient became hypertensive with a blood pressure of 207/123 mmHg. Intravenous metoprolol was administered. Severe pulmonary edema ensued, with resulting hypoxic respiratory failure and cardiogenic shock. The patient was transferred to a tertiary care facility for percutaneous cardiopulmonary bypass. After five days of cardiopulmonary bypass support and six weeks of intensive care monitoring, the patient's cardiac status returned to normal limits.


CONCLUSIONS
A hypertensive response, following systemically absorbed topical vasoconstrictors, including both phenylephrine and epinephrine, can be associated with dire consequences when treated with a beta-adrenergic blocking drug and, possibly, calcium channel blockers. To prevent severe complications including; pulmonary edema, cardiogenic shock, cardiac arrest, and, possibly, death, these drug interactions need to be appreciated.
Schwalm
Jon-David
JD
Hamilton Health Sciences-McMaster University, 237 Barton Street East, Hamilton, Ontario, Canada. schwalj@mcmaster.ca
Hamstra
Joel
J
Mulji
Amin
A
Velianou
James L
JL
D000319:Adrenergic beta-Antagonists / Q000009:adverse effects*; D000328:Adult; D004837:Epinephrine / Q000009:adverse effects*; D006801:Humans; D006973:Hypertension / Q000139:chemically induced / Q000188:drug therapy; D008297:Male; D008790:Metoprolol / Q000009:adverse effects*; D009300:Nasal Septum / Q000601:surgery*; D012770:Shock, Cardiogenic / Q000209:etiology*
D000319:Adrenergic beta-Antagonists; D008790:Metoprolol; D004837:Epinephrine