Publish in this journal
Journal Information
Vol. 56. Issue 6.
Pages 629-630 (June 2003)
Share
Share
Download PDF
More article options
Vol. 56. Issue 6.
Pages 629-630 (June 2003)
Full text access
Acute Myocardial Dysfunction After Nasal Infiltration With Cocaine
Disfunción miocárdica aguda reversible tras anestesia intranasal con cocaína
Visits
7404
Tomás Datinoa, Manuel Martínez-Sellésa, Juan Quilesa, Miriam Suáreza, Fernando Sarnago Cebadaa, Julio I Osendea
a Servicio de Cardiología. Hospital Gregorio Marañón. Madrid. España.
This item has received
7404
Visits
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Tables (2)
Fig. 1. M-mode echocardiogram done when the patient was in the ICU. Arrows indicate the diameters at end-diastole and end-systole of the left ventricle, which were 45 mm and 35 mm, respectively (shortening fraction 22%). Estimated ventricular function was 20%.
Fig. 2. Before discharge, the echocardiogram revealed full recovery of myocardial contractility (ejection fraction 60%). The end-diastolic and end-systolic diameters (arrows) were 43 mm and 25 mm (shortening fraction 22%).
Show moreShow less
We report the case of a patient with severe myocardial dysfunction after nasal infiltration of cocaine during septoplasty. Complete recovery of myocardial function was observed in twelve days. Several reports have described chronic cardiomyopathy in long-term cocaine users, but only one case of acute cardiomyopathy. None of these cases were related to the medical use of cocaine.
Keywords:
Cocaine
Contractility
Cardiomyopathy
Presentamos un caso de disfunción miocárdica aguda tras infiltración nasal con cocaína durante una septoplastia, con recuperación completa de la función miocárdica tras 12 días. En la bibliografía se han publicado casos de miocardiopatía crónica por consumo de cocaína, pero sólo uno de miocardiopatía aguda y ninguno en relación con su uso médico.
Palabras clave:
Cocaína
Contractilidad
Miocardiopatía
Full Text

INTRODUCTION

Cocaine is used in nasal surgery as a local anesthetic and vasoconstrictor. Its use is controversial due to its potential adverse cardiovascular side-effects.1 However, we are unaware of any published cases of acute, serious myocardial dysfunction after using cocaine as a local anesthetic.

CLINICAL CASE

A 22-year-old woman was admitted for a bilateral breast prosthesis and rhinoplasty for cosmetic reasons. She had used cocaine occasionally, but not within the last 6 months. Electrocardiogram (ECG) and preoperative analysis were normal.

Breast surgery was done without complications using oxygen and nitrogen protoxide (50:50), midazolam (3 mg), perfusion with remifentanyl and propofol, and the topical use of adrenaline (1 mg) and lidocaine. Subsequently, the nasal mucosa was infiltrated with lidocaine (40 mL, 1%), adrenaline (1 mg), and 2 mL of cocaine (40 mg). After 20 min, but before the rhinoplasty had begun, she presented hypoxemia and hypotension requiring orotracheal intubation and perfusion with dopamine. She was immediately transferred to our intensive care unit (ICU) with a blood pressure of 100/70 mm Hg and a heart rate of 112 beats/min, on inotropic support. The analysis showed: troponin T 0.56 ng/mL, CK-MB 15 U/mL, normal total CK, and high concentrations of cocaine in the urine (>600 ng/mL). An electrocardiogram showed nonspecific alterations and chest x-ray showed signs of acute lung edema. The patient required inotropic support to maintain blood pressure. She was extubated 10 h after admission.

At 36 h, a transthoracic echocardiogram showed acute biventricular systolic dysfunction with a left ventricular ejection fraction (LVEF) of 10%. A second echocardiogram done on the fifth day was similar to the first one with an LVEF of 20% (Figure 1).

Fig. 1. M-mode echocardiogram done when the patient was in the ICU. Arrows indicate the diameters at end-diastole and end-systole of the left ventricle, which were 45 mm and 35 mm, respectively (shortening fraction 22%). Estimated ventricular function was 20%.

After 6 days in the ICU she was moved to the cardiology wards. At that time she was hemodynamically stable, without inotropic support and without symptoms. On the 13th day, another echocardiogram showed an LVEF of 60%; all other parameters were normal (Figure 2). The patient was discharged without medical treatment.

Fig. 2. Before discharge, the echocardiogram revealed full recovery of myocardial contractility (ejection fraction 60%). The end-diastolic and end-systolic diameters (arrows) were 43 mm and 25 mm (shortening fraction 22%).

DISCUSSION

The recommended dose for local anesthesia with cocaine is 1­3 mg/kg, although toxicity has been des-cribed at doses of 30 mg.1 We used less than 1 mg/kg despite which concentrations in the urine were high. The patient assured us that she had not used cocaine for several months and, and even if she had in the last few days, given the half-life of cocaine, it is unlikely that this would have contributed to the situation. Cocaine users can have depressed asymptomatic myocardial contractility,2 but this is unlikely in this case as LVEF was normal at discharge. After cocaine is applied intranasally, peak values in plasma are reached within 15-60 min, which coincided with the onset of the cardiotoxicity we report.

Cocaine can produce acute deterioration of systolic and diasystolic function3 through several mechanisms.4,5 For example, it induces myocardial ischemia by coronary vasoconstriction, but the relatively few changes in the ECG, as well as her clinical evolution, echocardiography and tests, suggest this was not a determining factor in this patient. Cocaine can also depress myocardial contractility, depleting calcium levels in cardiac myocytes and reducing the response of cardiac myofibrils to calcium. It also blocks the reuptake of catecholamines, which can exert a toxic effect on the myocardium, as seen in pheochromocytoma. A case of acute, severe myocardial dysfunction after crack consumption was reported, where the patient spontaneously recovered after 2 weeks. A case of dilated cardiomyopathy was also reported which resolved 7 mo after cocaine use was stopped. In contrast to these cases, the acute myocardial dysfunction we have described was related to the medical use of cocaine.

In summary, we report a potentially fatal complication, previously undescribed, associated with the use of cocaine as an anesthetic in a healthy person. Thus, we recommend the use of safer and equally efficient alternatives to cocaine, such as lidocaine and tetracaine, as a local anesthetic.8




Correspondence: Dr. T. Datino Romaniega.
Servicio de Cardiología. Hospital Gregorio Marañón.
Dr. Esquerdo, 46. 28007 Madrid. España.
E-mail: tdr92@hotmail.com

Bibliography
[1]
Fleming JA, Byck R, Barash PG..
Pharmacology and therapeutic applications of cocaine..
Anesthesiology, 73 (1990), pp. 518-31
[2]
Chakko S, Fernández A, Mellman T..
Cardiac manifestations of cocaine abuse..
J Am Coll Cardiol, 20 (1992), pp. 1168-74
[3]
Pitts WR, Vongpatanasin W, Cigarroa JE, Hillis LD, Lange RA..
Effects of the intracoronary infusion of cocaine on left ventricular systolic and dyastolic function in humans..
Circulation, 97 (1998), pp. 1270-3
[4]
Lange RA, Hillis LD..
Cardiovascular complications of cocaine use..
N Engl J Med, 345 (2001), pp. 351-8
[5]
Castroseiros EF, Penas M, Castro A..
Patología del corazón de origen extracardíaco (VIII). Cocaína y corazón..
Rev Esp Cardiol, 51 (1998), pp. 396-401
[6]
Chokshi SK, Moore R, Pandian NG, Isner JM..
Reversible cardiomyiopathy associated with cocaine intoxication..
Ann Intern Med, 111 (1989), pp. 1039-40
[7]
Hezlova MJ, Smith SH, Perchal VM, Helmeke FR..
Apparent reversivility of cocaine-induced congestive cardiomyopathy..
Am Heart J, 122 (1991), pp. 577-9
[8]
Latorre F, Klmek L..
Does cocaine still have a role in nasal surgery?.
Drug Saf, 20 (1999), pp. 9-13
Idiomas
Revista Española de Cardiología (English Edition)

Subscribe to our newsletter

Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

es en
Política de cookies Cookies policy
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.