Sudden pulmonary edema induced by phenylephrine misuse: a case report

Qing  Xie; Dong-Dong  Tian; Jia Lu

doi:10.2298/VSP250801022X

Qing Xie Zhejiang University School of Medicine, First Affiliated Hospital, Department of Anesthesia, Hangzhou, Zhejiang, China
Dong-Dong Tian Zhejiang University School of Medicine, First Affiliated Hospital, Department of Anesthesia, Hangzhou, Zhejiang, China
Jia Lu Fudan University, Shanghai Medical College, Huashan Hospital, Department of Anesthesia, Shanghai, China

DOI: https://doi.org/10.2298/VSP250801022X

Keywords: anesthesia, intravenous;, anesthesiologists;, intensive care units;, medical errors;, phenylephrine;, pulmonary edema.

Abstract

Introduction. Phenylephrine, a widely used vasoactive drug in clinical practice, may lead to severe cardiovascular complications when misused. Among these complications, sudden pulmonary edema, though rare, warrants the attention of clinicians. The given case report presents a sudden pulmonary edema caused by the misuse of phenylephrine. Case report. A female patient aged 68-years undergoing radical mastectomy for left breast cancer developed severe hypertension and hypoxemia 40 min into the procedure. The patient’s medical history included meningioma but no other significant comorbidities. A diagnosis of sudden (acute) pulmonary edema was made. The patient received prompt treatment, including strict perioperative blood pressure control, lung protective ventilation, glucocorticoids, diuretics, coronary-dilation and cardiotonic drugs, postoperative oxygen therapy, and continuous vital sign monitoring. Investigation revealed that phenylephrine had been mistakenly administered intravenously instead of dexamethasone. She recovered and was discharged one week postoperatively. Conclusion. This case highlights the risks associated with the inadvertent administration of a high dose of phenylephrine, leading to sudden pulmonary edema. It underscores the importance of vigilance among anesthesiologists, prompt management of complications, and strategies to prevent errors, including enhanced education for resident anesthesiologists, measures to address practitioner fatigue, and improved drug packaging to minimize look-alike errors.

References

Macmillan M, Barker K. Phenylephrine toxicity. Eur J Anaes-thesiol 2008; 25(5): 426–7. DOI: 10.1017/S0265021507002785.

Constantine ST, Gopalsami A, Helland G. Recurrent Priapism Gone Wrong: ST-Elevation Myocardial Infarction and Cardi-ogenic Shock After Penile Corporal Phenylephrine Irrigation. J Emerg Med 2017; 52(6): 859–62. DOI: 10.1016/j.jemermed.2017.01.055.

Kalyanaraman M, Carpenter RL, McGlew MJ, Guertin SR. Cardi-opulmonary compromise after use of topical and submucosal alpha-agonists: possible added complication by the use of be-ta-blocker therapy. Otolaryngol Head Neck Surg 1997; 117(1): 56–61. DOI: 10.1016/S0194-59989770207-9.

Krovvidi H, Kulkarni PR. Management of intraoperative pul-monary oedema in a child following systemic absorption of phenylephrine eyedrops. Br J Anaesth 2002; 89(2): 343; au-thor reply 343–4. DOI: 10.1093/bja/aef525.

Baldwin FJ, Morley AP. Intraoperative pulmonary oedema in a child following systemic absorption of phenylephrine eyedrops. Br J Anaesth 2002; 88(3): 440–2. DOI: 10.1093/bja/88.3.440.

Greher M, Hartmann T, Winkler M, Zimpfer M, Crabnor CM. Hypertension and pulmonary edema associated with subcon-junctival phenylephrine in a 2-month-old child during cataract extraction. Anesthesiology 1998; 88(5): 1394–6. DOI: 10.1097/00000542-199805000-00032.

Gonçalves L, Luís M. Acute Pulmonary Edema During a Cesar-ean Delivery After an Adverse Drug Event. Cureus 2022; 14(12): e32876. DOI: 10.7759/cureus.32876.

Rimoldi SF, Yuzefpolskaya M, Allemann Y, Messerli F. Flash pulmonary edema. Prog Cardiovasc Dis 2009; 52(3): 249–59. DOI: 10.1016/j.pcad.2009.10.002.

Dubost C, de Saint Maurice G, Vichard A, Berbari H, Lenoir B. Right to the heart: a case of accidental phenylephrine intoxi-cation. Eur J Anaesthesiol 2011; 28(9): 670–2. DOI: 10.1097/EJA.0b013e32834753fa.

Mottram PM, Haluska BA, Leano R, Carlier S, Case C, Marwick TH. Relation of arterial stiffness to diastolic dysfunction in hypertensive heart disease. Heart 2005; 91(12): 1551–6. DOI: 10.1136/hrt.2004.046805.

Januzzi JL, van Kimmenade R, Lainchbury J, Bayes-Genis A, Or-donez-Llanos J, Santalo-Bel M, et al. NT-proBNP testing for di-agnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J 2006; 27(3): 330–7. DOI: 10.1093/eurheartj/ehi631.

Mantzourani E, Desselle S, Le J, Lonie JM, Lucas C. The role of reflective practice in healthcare professions: Next steps for pharmacy education and practice. Res Social Adm Pharm 2019; 15(12): 1476–9. DOI: 10.1016/j.sapharm.2019.03.011.

Mamede S, Schmidt HG, Penaforte JC. Effects of reflective prac-tice on the accuracy of medical diagnoses. Med Educ 2008; 42(5): 468–75. DOI: 10.1111/j.1365-2923.2008.03030.x.

Li H, Zuo M, Gelb AW, Zhang B, Zhao X, Yao D, et al. Chinese Anesthesiologists Have High Burnout and Low Job Satisfac-tion: A Cross-Sectional Survey. Anesth Analg 2018; 126(3): 1004–12. DOI: 10.1213/ANE.0000000000002776.

Afonso AM, Cadwell JB, Staffa SJ, Sinskey JL, Vinson AE. U.S. Attending Anesthesiologist Burnout in the Postpandemic Era. Anesthesiology 2024; 140(1): 38–51. DOI: 10.1097/ALN.0000000000004784.