Peri-Operative MI after Intranasal Application of Cocaine for Transnasal Procedure

Introduction: Topical cocaine is widely used by otolaryngologists during endonasal surgeries. However, its adverse cardiac effects such as tachyarrhythmias, hypertension, myocardial infarction, and cardiogenic shock limit its therapeutic use in patients with a history of cardiac disease and cardiac risk factors. Most practices suggest that the use of topical cocaine in patients without cardiac disease is relatively safe. We report a case of NSTEMI following the use of topical cocaine during endonasal surgery in a patient without any known history of cardiac disease or hypertension, and who had patent coronary vessels on subsequent angiography.

Case Presentation: A 55 year old man without any previous history of cardiac disease or hypertension was admitted for endoscopic transphenoidal resection of a pituitary macroadenoma. His preoperative ECG (Fig. 1) and laboratory tests were all normal. His calculated perioperative cardiac risk was 0.4–1.0%. After safe induction of general anesthesia and intubation, 4% cocaine soaked pledgets were inserted into the nasal cavity bilaterally for ∼30 minutes. The pledgets were removed and the nasal cavities were injected with 1% lidocaine and adrenaline 1:100,000. The endoscope was then inserted in the left nasal cavity. However, the patient developed episodes of nonsustained ventricular tachyarrhythmia. The procedure was immediately aborted. He subsequently developed bradycardia and marked ST segment depressions in the precordial leads (Fig. 2), which self-resolved after 15–20 minutes. The patient remained hemodynamically stable throughout the entire cardiac event. Cardiology was called to the operating room. A transesophageal echocardiogram was performed, which showed no gross wall movement abnormalities. The patient had no further cardiac events for the remainder of the hospital stay (Fig. 3), and was transferred to the cardiac ICU in stable condition for further workup. A peak Troponin T of 0.45 demonstrated the presence of an NSTEMI. The patient's lipid profile demonstrated elevated cholesterol of 294, but normal LDL and triglycerides. Cardiac angiography revealed patent coronary vessels without signs of stenosis and a normal LVEF of 60%. After thorough workup, it was determined the NSTEMI was related to transient coronary vasospasm in the setting of topical cocaine. Two weeks later, the patient was deemed safe for reoperation. The circumstances surrounding the initial cardiac event were discussed, and it was concluded that the safest way to proceed would be to perform the procedure with oxymetazoline instead of cocaine and adrenaline. The patient tolerated the procedure well without any complications and was discharged in stable condition the following day.

Conclusion: This case illustrates topical cocaine induced myocardial infarction during endonasal surgery in a patient without a history of cardiac disease or hypertension, and with patent coronary vessels confirmed by angiography. Topical cocaine-based preparations must therefore be used with caution in all patients undergoing endonasal surgery regardless of their cardiovascular risk profile. Furthermore, it adds to a growing literature demonstrating the availability of alternative preparations of topical anesthetics and vasoconstrictors that appear to be safer and equally efficacious when compared with cocaine-based preparations for use during endonasal procedures.