Unexpected intraoperative hypotension in a chronic cocaine user

It is not uncommon for patients to present for procedures under anaesthesia with a history of recent cocaine use. The acute effects of cocaine toxicity are well documented, but the pathophysiological changes caused by chronic use are complex and can result in unexpected cardiovascular responses and interactions with anaesthetic agents. In this case report, we describe an episode of hypotension under general anaesthesia, likely due to catecholamine depletion, an unusual but significant consequence of chronic cocaine use. It should be treated with intravenous fluids and direct-acting vasopressors such as phenylephrine or noradrenaline, as they are likely to be more effective than indirect acting agents. As the prevalence of cocaine use continues to increase, anaesthesia providers need to not only be familiar with the treatment of acute cocaine toxicity, but also to anticipate and manage the cardiovascular changes associated with chronic use of this drug.