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Hypertension and vasospasm, leading to coronary artery dissection: case report A 37-year-old woman developed hypertension and vasospasm, leading to a coronary artery dissection following administration of phenylephrine and ephedrine during a caesarean section. The woman underwent induction of spinal anaesthesia with bupivacaine and diamorphine. She then commenced an infusion of phenylephrine 100 µg/mL at 20 mL/h. Five minutes after induction, she became hypotensive and bradycardic. She was administered IV ephedrine 9mg; however, her HR and BP continued to drop. She received atropine and IV ephedrine 15mg, after which her HR and BP rapidly increased to 140 beats/min and 188/99mm Hg, respectively. She then developed dyspnoea and felt flushed [time to reaction onset not stated]. The woman’s phenylephrine infusion was discontinued, and surgery was performed. Following delivery, her dyspnoea persisted and she had a pulse oximetry of 89% on oxygen. Auscultation revealed fine inspiratory crepitations. During recovery, she received furosemide for a suspected acute left ventricular failure. Her hypoxaemia subsequently resolved. Chest x-ray, 12-lead ECG and transthoracic echocardiography were indicative of a non-ST elevation myocardial infarction. She received aspirin and enoxaparin sodium. Urgent cardiac catheterisation revealed a probable dissection of the left anterior descending artery. A coronary artery spasm was thought to have occurred, and she commenced bisoprolol. One week after the caesarean section, she was discharged with no cardiac abnormalities or residual symptoms. Author comment: "[O]ur patient suffered a probable coronary artery dissection . . . possibly precipitated by hypertension and vasospasm resulting from the administration of high doses of ephedrine and a background phenylephrine infusion." Newell CP, et al. Case report: spontaneous coronary artery dissection during elective caesarean section under spinal anaesthesia. Anaesthesia 66: 615-9, No. 7, Jul 2011. Available from: URL: http://dx.doi.org/10.1111/ 803061333 j.1365-2044.2011.06697.x - United Kingdom

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Reactions 15 Oct 2011 No. 1373