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Case report: Profound hypotension associated with labetalol therapy in a patient with cerebral aneurysms and subarachnoid hemorrhage

[Une hypotension profonde associée au labétalol chez un patient qui présente des anévrysmes cérébraux et une hémorragie sous-arachnoïdienne]

Sana Jivraj^*, C. David Mazer, MD^*,, Andrew J. Baker, MD^*, Mabel Choi, MD and Gregory M.T. Hare, MD PhD^*,

^* From the Departments of Anesthesia, Cara Phelan Centre for Trauma Research, St. Michael’s Hospital, University of Toronto,
Department of Physiology, University of Toronto, and the
Department of Anesthesia, Sunnybrook and Women’s Health Sciences Centre, Toronto, Ontario, Canada.

Address correspondence to: Dr. Gregory M.T. Hare, Departments of Anesthesia and Physiology, University of Toronto, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada. Phone: 416-864-5825; Fax: 416-864-6014; E-mail: hareg{at}smh.toronto.on.ca

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 an iv 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.

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