2016 FSA Posters

P009: HYPERTENSIVE CRISIS FROM ADRENAL STIMULATION FROM THE AQUAMANTYS
Brian Hardy, MD, Christopher Giordano, MD; University of Florida

Introduction: Hypertension is commonly encountered during general anesthesia. Aside from pathological causes of hypertension, rarely is hypertension extreme and sustained enough to be classified as a hypertensive crisis [systolic blood pressure (SBP) > 180 mmHg or diastolic blood pressure (DBP) > 120 mmHg]. To date, no reports have been made of adrenal stimulation with the use of bipolar sealing for hemostasis. We report a case in which a hypertensive crisis (SBP > 300 mmHg) was encountered with the use of bipolar sealing during a liver transplant.

Case Presentation: A 55-year-old female with a history of hemochromatosis was scheduled for a liver transplant. She was admitted 5 days prior for hepatic failure complicated by acute renal failure requiring dialysis and acute respiratory distress syndrome.  She had no known history of adrenal disease. Work-up for liver transplant did not show any thyroid dysfunction. She was induced with general anesthesia and an arterial line and triple lumen central line were placed without complication.  After anesthetic induction, SBP ranged from 109 to 151 mmHg.    

Hemostasis during the procedure was accomplished with bipolar sealing through the Aquamantys system. Bipolar sealing uses radiofrequency energy in combination with heated saline to provide broad tissue hemostasis. Hemostasis is achieved through controlled thermal energy transmitted to tissues at 100 °C, reducing charring and eschar formation. Preliminary studies indicate that bipolar sealing may reduce blood transfusions during and after liver surgery secondary to decreased bleeding.

During the anhepatic phase of the procedure, bipolar sealing was used for hemostasis in the right retroperitoneum.  An acute rise in blood pressure was immediately noted with SBP rising from 150 to over 300 mmHg and a rise in the mean arterial pressure from 118 to 204 mmHg.  Heart rate increased from 103 bpm to 123 bpm. Upon recognition of these changes, surgical manipulation was stopped and anesthesia equipment was confirmed to be functioning correctly. Blood pressure was treated with 80 mcg of nitroglycerin in divided doses as well as an increased concentration of isoflurane. Return to baseline blood pressure was noted within 6 minutes. It was concluded that the use of bipolar sealing in the right retroperitoneum had stimulated the adrenal glands, resulting in a surge in stored catecholamines into circulation. No further acute changes in blood pressure were noted during the case. 

At the conclusion of the case, the patient was taken to the surgical intensive care unit, extubated on postoperative day 3, and discharged from the hospital on postoperative day 15. No further blood pressure complications were noted in the hospital course.

Conclusion: Although rare, intraoperative stimulation of adrenal glands resulting in discharge of catecholamines represents an acute crisis in anesthetic management, surgical manipulation in the retroperitoneum increases this risk. Electrocautery has been reported to cause a hypertensive crisis through simulation of the adrenal gland. This case is an example of a hypertensive crisis as a result of adrenal stimulation using bipolar sealing. Blood pressure was managed with cessation of surgical stimulation, treatment with nitroglycerin, and deepening anesthesia.