Abstract
Purpose
Labetalol is an effective antihypertensive medication frequently used to treat systemic hypertension in acute care settings, including the management of hypertension associated with a subarachnoid hemorrhage. We present a case of profound hypotension, refractory to inotropic and vasopressor therapy following an iv infusion of labetalol.
Clinical features
Initiation of aniv labetalol infusion resulted in good blood pressure control in a patient suffering from a Fisher grade 3 subarachnoid hemorrhage with an initial Glascow coma scale of 14/15 and mild hydrocephalus. Progressive deterioration of neurological symptoms and evidence of worsening hydrocephalus preceded the sudden development of profound hypotension (60/35 mmHg) and bradycardia with a minimum heart rate of 40 beats·min-1. Initial resuscitative efforts included administration of intravascular fluid, hypertonic saline, atropine, adrenalin (more than 10 mg in divided doses) and noradrenalin. These measures restored the blood pressure to 80/45 with a HR of 98 beats·min-1. Intraoperative placement of an intraventricular drain released cerebrospinal fluid under pressure with an initial intracranial pressure of 15 cm H2O. A combination of adrenalin, noradrenalin, dopamine and vasopressin infusions were required to restore the blood pressure to 130/65 mmHg after an additional two hours. All inotropic and vasopressor support was weaned off after the 14th hr (about two drug half-lives). The patient was awake and responsive the following day, with no obvious neurological consequences. No evidence of neurological injury, drug administration error or myocardial dysfunction was documented.
Conclusion
The episode of profound hypotension which occurred after initiating a labetolol infusion required maximal combined vasopressor therapy to restore the blood pressure suggesting that this patient demonstrated an extreme sensitivity to labetalol. Combination therapy with adrenergic and nonadrenergic agonists may be required for optimal treatment of profound hypotension associated with labetalol-induced vasoplegia.
Résumé
Objectif
Le labétalol est un antihypertenseur efficace souvent utilisé contre l’hypertension généralisée dans le cadre de soins actifs, y compris le traitement de l’hypertension associée à une hémorragie sous-arachnoïdienne. Nous présentons un cas d’hypotension profonde, réfractaire aux inotropes et aux vasopresseurs à la suite d’une perfusion iv de labétalol.
Éléments cliniques
Ľadministration d’une perfusion iv de labétalol a bien contrôlé la tension artérielle chez un patient souffrant d’une hémorragie sous-arachnoïdienne de grade 3 de Fisher accompagnée d’un coma initial de 14/15 à l’échelle de Glasgow et d’une légère hydrocéphalie. La détérioration neurologique progressive et l’aggravation évidente de l’hydrocéphalie ont précédé le développement soudain d’une profonde hypotension (60/35 mmHg) et de bradycardie avec une fréquence cardiaque (FC) minimale de 40 battements·min-1. La réanimation a d’abord consisté en l’administration intravasculaire de liquide, de solution saline hypertonique, d’atropine, d’adrénaline (plus de 10 mg en doses divisées) et de noradrénaline. La tension artérielle a été restaurée à 80/45 avec une FC de 98 battements·min-1. La mise en place peropératoire d’un drain intraventriculaire a libéré du liquide céphalorachidien sous pression pour une pression intracrânienne initiale de 15 cm H2O. Des perfusions combinées d’adrénaline, de noradrénaline, de dopamine et de vasopressine ont permis de restaurer la tension artérielle à 130/65 mmHg, deux heures plus tard. Toute assistance inotropique et vasopressive a été retirée après la 14e h (environ Competing interests: None declared. deux demi-vies du médicament). Le patient était éveillé et apte à réagir le jour suivant, sans séquelles neurologiques apparentes. Aucune évidence de lésion neurologique, d’erreur d’administration de médicament ou de dysfonction myocardique n’ont été documentées.
Conclusion
Ľépisode d’hypotension profonde survenue après l’administration d’une perfusion de labétalol a nécessité un traitement vasopresseur maximal combiné pour restaurer la tension artérielle, ce qui laisse croire que ce patient a démontré une extrême sensibilité au labétalol. La combinaison d’agonistes adrénergiques et non adrénergiques peut être nécessaire comme traitement optimal de l’hypotension profonde associée à la vasoplégie induite par le labétalol.
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Jivraj, S., Mazer, C.D., Baker, A.J. et al. Case report: Profound hypotension associated with labetalol therapy in a patient with cerebral aneurysms and subarachnoid hemorrhage. Can J Anesth 53, 678–683 (2006). https://doi.org/10.1007/BF03021626
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DOI: https://doi.org/10.1007/BF03021626