Hyperventilation syndrome following epinephrine nasal packing for intubation-related epistaxis: a case report

Epistaxis is the most common complication of nasotracheal intubation. Epinephrine-impregnated nasal gauze packing is usually employed as a hemostatic method for intubation-induced epistaxis. Systemic absorption of the topically administered epinephrine may lead to adverse effects. Currently reported adverse events associated with topical epinephrine administration are predominantly cardiovascular reactions. Here we describe a rare case of hyperventilation syndrome potentially induced by epinephrine-impregnated nasal packing for treatment of epistaxis in a patient who underwent nasotracheal-intubated maxillofacial surgery. A 29-year-old woman was scheduled to undergo nasally-intubated general anesthesia for surgical curettage and extraction of a maxillary cyst. The patient had no significant family or personal medical history except for hepatitis B virus infection. After an uneventful procedure and smooth emergence, the patient developed significant epistaxis. To stop the bleeding, the attending physician packed the nasal cavity with epinephrine-impregnated gauze (1:20,000). The bleeding was arrested 10 min after the epinephrine gauze was applied. Throughout this process, the patient remained awake and cooperative with no reported discomfort. Fifteen minutes after the epinephrine gauze was applied, the patient complained of difficulty breathing, palpitations, chest tightness, and paresthesia and tetany in the four extremities. The patient’s vital signs showed a sinus tachycardia and tachypnea (respiratory rate 23 breaths per minute). Arterial blood gas analysis revealed acute respiratory alkalosis. The patient was diagnosed with hyperventilation syndrome. Low-flow oxygen (3 L/min) was delivered with a reservoir bag mask. We also provided verbal reassurance to alleviate her anxiety and instructed her to consciously slow her breathing. Thirty minutes later, the patient recovered from hyperventilation. She experienced no other adverse event and was discharged two days after surgery. We report a case of a healthy patient without preexisting anxiety who developed hyperventilation following nasal packing with epinephrine-impregnated gauze to control epistaxis after extubation. Our experience demonstrates that when using epinephrine to treat epistaxis, in addition to monitoring circulatory status, we should be vigilant about its potential risk to ventilatory function.