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Drug-Induced Sleep Endoscopy DISE with Target Controlled Infusion TCI and Bispectral Analysis in Obstructive Sleep Apnea

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Refractory intraoperative hypotension with elevated serum tryptase.

Juraj Sprung¹, Kelly J Larson¹, Rohit D Divekar²

¹Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA.

Asia Pacific Allergy

|February 6, 2015

Summary

Patients on lisinopril may experience severe hypotension during surgery. This case highlights that uninterrupted lisinopril therapy, not an allergic reaction, can cause refractory hypotension and elevated tryptase levels.

Keywords:

Anaphylaxis Hypotension Lisinopril Mastocytosis Renal insufficiency, Chronic Tryptase

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Area of Science:

Anesthesiology
Nephrology
Clinical Pharmacology

Background:

Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor subtype 1 antagonists (ARBs) are commonly used antihypertensive medications.
Intraoperative hypotension is a known risk in patients taking these medications.
Mast cell activation, indicated by elevated serum tryptase, can mimic allergic reactions.

Observation:

A patient on lisinopril developed severe, refractory intraoperative hypotension.
The patient presented with an elevated serum tryptase level, initially suggesting an allergic reaction.
Standard allergy workup excluded mast cell activation and mastocytosis.

Findings:

The refractory hypotension was ultimately attributed to the uninterrupted administration of lisinopril during surgery.
Elevated serum tryptase levels in this patient were likely due to chronic renal insufficiency, not mast cell activation.
This case underscores the potential for ACEi to cause severe hypotension independent of allergic responses.

Implications:

Anesthesiologists should consider the impact of ACEi on hemodynamic stability during surgery.
Discontinuation or careful management of ACEi therapy may be necessary in certain surgical contexts.
Elevated serum tryptase in the context of renal insufficiency and ACEi use requires careful interpretation to avoid misdiagnosis of allergic reactions.