Refractory Distributive Shock in Complex Spine Surgery: A Rare Entity That Needs Recognition – Case Series

ABSTRACT: Vasoplegia is a form of vasodilatory shock characterized by low systemic vascular resistance and severe hypotension with normal or high cardiac output that is unresponsive to volume resuscitation and conventional vasopressors. Its occurrence after major complex spine surgery has rarely been reported. Hypotension during complex spine surgery is associated with increased perioperative morbidity. This case series describes the management of refractory distributive shock of unknown cause in patients who underwent complex spine surgery. Three American Society of Anesthesiologists (ASA-1) patients underwent complex spine surgery involving spinal cord manipulation/retraction/stretching. All three patients encountered severe refractory hypotension toward the end of the surgery without any obvious causes of hypotension (hypovolemia, anaphylaxis, spinal shock, cardiogenic, embolic, or pneumothorax). All patients were treated with high doses of noradrenaline and vasopressin for 12-36 h after surgery. All patients had good neurological outcomes despite transient severe hypotension. Awareness of this entity helps anesthesiologists manage hypotension by early institution of nonconventional vasopressors (e.g., vasopressin) after ruling out other causes.