Cardiovascular crisis induced by local epinephrine injection in vaginal tightening surgery: an unexpected hyperthyroidism case

The submucosal injection of epinephrine-saline solution is a common technique in vaginal tightening surgery to facilitate hydrodissection and minimize bleeding. Furthermore, the vaginal mucosa is highly vascular, which predisposes to rapid systemic absorption of epinephrine and potential triggering of tachycardia and hypertension. Moreover, as patients undergoing such non-thyroid procedures often do not receive preoperative thyroid function assessment, the presence of undiagnosed hyperthyroidism can markedly potentiate the cardiovascular effects of epinephrine, thereby increasing the risk of perioperative cardiovascular events and presenting a significant challenge for anesthetic management. This article reports a case of a 29-year-old female patient who experienced a malignant cardiovascular event during vaginal tightening surgery after submucosal injection of 10 mL of 1:400,000 adrenaline. The event manifested initially as sinus tachycardia and severe hypertension. After intravenous administration of esmolol, the condition deteriorated into ventricular tachycardia, ventricular fibrillation, and subsequent cardiac arrest. Sinus rhythm was restored following cardiopulmonary resuscitation and defibrillation. Postoperative evaluation of the newly diagnosed patient with hyperthyroidism. Upon retrospective analysis, we attribute this event to an epinephrine-triggered reaction in the setting of undiagnosed hyperthyroidism, which was potentially exacerbated by the β-blocker (esmolol). The event was not considered a thyroid storm. The patient recovered fully and was discharged after two days of treatment without requiring antithyroid medication. We strongly advocate for the routine inclusion of thyroid function tests in the preoperative evaluation of patients scheduled to receive epinephrine. In patients with conditions predisposing them to heightened catecholamine sensitivity, such as undiagnosed hyperthyroidism, local or submucosal epinephrine should be used with extreme caution due to the risk of potential cardiovascular side effects. Should a severe perioperative epinephrine-related cardiovascular event occur, a multidisciplinary approach is imperative. Furthermore, the use of β-blockers requires careful consideration in this context.