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Absence of pulse and blood pressure following vasopressin injection for myomectomy

Royal Victoria Hospital, McGill University, Montreal, Canada, E-mail: alain.deschamps{at}staff.mcgill.ca

To the Editor:

Complications from vasopressin injection into the uterine wall to limit blood loss during myomectomies¹ appear to be rare. We found one report of pulmonary edema and cardiac arrhythmias after vasopressin injection.² We present the case of a healthy 31-yr-old woman who received a combined spinal epidural with 5 mg of bupivacaine, 25 µg of sufentanyl, and 0.25 mg of preservative-free morphine intrathecally. General anesthesia was induced with 2 mg·kg^–1 propofol iv and maintained with 0.6 MAC desflurane. The blood pressure (BP) decreased to 80/45 mmHg post induction. Heart rate (HR) was 67 beats·min^–1. Phenylephrine, 0.1 mg iv, easily corrected the BP and four additional doses were needed before vasopressin injection. There was no hemodynamic response with skin incision. After exteriorization of the uterus and verification that the needle was not intravascular, 3 U of a 0.5 U·mL^–1 solution of vasopressin were injected into the uterine wall. The next BP cycle did not register a value, HR was 45 beats·min^–1 and 5 mg of ephedrine were given twice for presumed hypotension. The pulse oximeter became flat. The ECG showed normal sinus rhythm. Bilateral radial pulses were absent, but a faint carotid pulse was palpable. The skin colour did not change and the mucus membranes were pink. The electrocardiogram (ECG) changed to an atrioventricular block with bigemmini at 45 beats·min^–1. There was no change in the end-tidal CO₂. The surgeon communicated that the bleeding was brisk. We assumed the cause to be intravascular vasopressin, and decided to continue the surgery while giving 50 mg of propofol iv and increasing desflurane to 2 MAC. The pulse oximeter reappeared five minutes later at 100% saturation with a BP of 198/95 mmHg at 60 beats·min^–1. The BP normalized after 15 min of additional propofol and desflurane, and the patient had an uneventful postoperative recovery.

Combining regional and general anesthesia for laparotomy is common practice. This strategy dampens the stress response but may result in hypotension. In this case, because the hypotension needed correction even after skin incision and because vasopressin rarely has systemic effects, the disappearance of vital signs was misleading. However, the overall evaluation of the patient was not compatible with cardiovascular collapse and the duration of the events corroborates well with vasopressin’s half-life of 30 to 60 min. An atrioventricular block has been described previously,² but we were not aware of this at the time. Since there was no visual evidence of intravascular injection of vasopressin by the surgeons, we can only advise that vasopressin be injected slowly, without using excessive pressure, to avoid intravascular spreading.

References

1 Fletcher H, Frederick J, Hardie M, Simeon D. A randomized comparison of vasopressin and tourniquet as hemostatic agents during myomectoy. Obstet Gynecol 1996; 87: 1014–8.[Abstract]

2 Tulandi T, Beique F, Kimia M. Pulmonary edema: a complication of local injection of vasopressin at laparoscopy. Fertil Steril 1996; 66: 478–80.[Medline]

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