Prior to Incision II

This is a continuation of the case described yesterday. My attending and I scrambled to resuscitate this anesthetized patient, staving off a code and trying to figure out what was going on. I ended up pushing several sticks of phenylephrine and ephedrine, and finally we resorted to epinephrine. With just a touch of epinephrine, the patient's blood pressures and oxygen saturation shot back to normal. We ended up proceeding with the surgery, and although she required some mild vasopressors during the case, her vitals remained reasonable. After extubation, she did fine.

In the end, our hypothesis was that this patient had red (wo)man syndrome from vancomycin administration. Although she had tolerated vancomycin in the past, perhaps the rate we were administering it led to a transient vasodilation. On the floor, vancomycin is given quite slowly, but in the operating room, we administer it quicker to make sure we have systemic levels of antibiotics prior to incision (especially in a patient who has a history of prosthetic infections). Furthermore, co-administration of opiates and smooth muscle relaxants increases likelihood of red man syndrome. Mast cell degranulation and histamine release leads to transient hypotension and erythema; indeed under the drapes we noted a macular rash. Luckily, despite hemodynamic instability, this syndrome is rarely life-threatening.