Case 29: Intraoperative Hypotension

  • John G. Brock-Utne


A 5-year-old boy (12 kg) with a 36-h history of nausea and vomiting is admitted to the hospital. The child has a history of hydrocephalus and seizure disorder. A ventriculoperitoneal shunt, placed uneventfully under general anesthesia several years before, is seen to be working adequately. His medication consists of carbamazepine, 20 mg/kg per day. The patient has no history of drug allergy, nor is there any adverse family history of anesthetic complications. On examination, the child is listless, with other clinical signs of hypovolemia (skin turgor, mucous membranes, peripheral shut down). A chest X-ray shows bowel in the left hemithorax, and a presumptive diagnosis of a hernia of Morgagni is made. A pediatric surgeon is called. The child is rehydrated over a 2-h period and the blood electrolytes are normal. A rapid-sequence induction/intubation is performed without any difficulty (ketamine, 20 mg, and rocuronium, 20 mg) at 3:00 AM. Anesthesia is maintained with oxygen in air and isoflurane 0.3–0.5%. A thoracic epidural catheter is placed 15 min later, and 9 ml of 0.25 % bupivacaine with 0.2 mg hydromorphone (Dilaudid) is injected. At 3:30 AM, cefazolin (Kefzol), 500 mg intravenous (IV), is administered, and at 4:15 AM, the surgeons have full exposure of the hernia through a laparotomy incision. At 4:20 AM, the blood pressure (BP) drops precipitously, with hardly a change in heart rate. Peak inspired pressure and tidal volume are not changed. The SPO2 is 100 % on 100 % FIO2, and his temperature is normal. Ephedrine, 2 mg, has no effect, and the BP drops to 50 mmHg. Epinephrine, 5–20 μ(mu)g, is used to maintain the BP. The heart rate drops from 110 to 80. You consider the following causes of this intraoperative hypotension: overdose of bupivacaine and/or of inhalation anesthetic and allergic reactions to muscle relaxants and/or antibiotics.


Natural Rubber Spina Bifida Ventriculoperitoneal Shunt Peak Inspire Pressure Latex Rubber 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Blanco I, Cardenas E, Aguilera L, Camino E, Arizaga A, Telletxea S. Serum tryptase measurement in diagnosis of intraoperative anaphylaxis caused by hydatid cyst. Anaesth Intensive Care. 1996;24:489–91.PubMedGoogle Scholar
  2. 2.
    Gold M, Swartz JS, Braude BM, Dolovich J, Shandling B, Gilmour RF. Intraoperative anaphylaxis: an association with latex sensitivity. J Allergy Clin Immunol. 1991;87:662–6.PubMedCrossRefGoogle Scholar
  3. 3.
    Moscicki RA, Sockin SM, Corsello BF, Ostro MG, Bloch KJ. Anaphylaxis during induction of general anesthesia: subsequent evaluation and management. J Allergy Clin Immunol. 1990;86:325–31.PubMedCrossRefGoogle Scholar
  4. 4.
    Fisher MM, More DG. The epidemiology and clinical features of anaphylactic reaction in anaesthesia. Anaesth Intensive Care. 1981;9:226–34.PubMedGoogle Scholar
  5. 5.
    Slater JE, Mostello LA, Shaer C. Rubber-specific IgE in children with spina bifida. J Urol. 1991;146:578–9.PubMedGoogle Scholar
  6. 6.
    Nutter AF. Contact urticaria to rubber. Br J Dermatol. 1979;101:597–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Sethna NF, Sockin SM, Holzman RS, Slater JE. Latex anaphylaxis in a child with a history of multiple anesthetic drug allergies. Anesthesiology. 1992;77:372–5.PubMedCrossRefGoogle Scholar
  8. 8.
    Turjarimaa K, Reunala T, Rasanen L. Comparison of diagnostic methods in latex surgical glove contact urticaria. Contact Dermatitis. 1988;19:241–7.CrossRefGoogle Scholar
  9. 9.
    Swartz JS, Gold M, Braude BM, Dolovich J, Gilmour RF, Shandling B. Intraoperative anaphylaxis to latex: an identifiable population at risk. Can J Anaesth. 1990;37(4 Pt 2):S131.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • John G. Brock-Utne
    • 1
  1. 1.Department of AnesthesiaStanford UniversityStanfordUSA

Personalised recommendations