CLINICAL EPISODE OF CORONARY ARTERY SPASM AFTER ADMINISTRATION OF NOREPINEPHRINE IN DENGUE SHOCK

Abstract

INTRODUCTION:   Dengue Shock Syndrome (DSS) is associated with high mortality and the role of inotropic and vasopressor agents is very important in the management.

CASE REPORT: 35-year-old woman presented with fever for 3 days associated with vomiting and headache. She was treated as DSS with positive NS-1 test. She however remained hypotensive with blood pressure of 80/50mmHg after 40ml/kg of fluid resuscitation. She was subsequently started on a low dose, single strength intravenous norepinephrine infusion (IVI NE). However after 10 minutes, she developed suddent onset of chest pain and dizziness with episode of bradycardia with the heart rate crashed to 30-40 bpm and blood pressure of 60/40mmHg. Cardiac monitor showed junctional bradycardia. Subsequent ECG showed ST-elevation at AVR, ST-depression II, III, AVF, V2-V6. She was given IV atrophine 0.5mg and her symptom completely resolved and IVI NE was stopped. A repeated ECG showed normal sinus rhythm. IVI Dopamine was therefore commenced without any side effect or complications.

DISCUSSION: The administration of fluid is the first line management in distributive shock, but the adrenergic agent is always needed to correct the hypotension. NE are among the commonest used. Drug induced myocardial infarction in the majority of cases it has been related with coronary artery spasm (CAS). CAS is a sudden tightening of the muscles within the arteries. IVI NE can cause increase cardiac blood flow, a reflex bradycardia and also has the effect of vasoconstrictive that leads to narrowing of the arteries and prevent blood from flowing to the heart. Patients on vasopressors require continuous hemodynamic monitoring such as blood pressure, pulse rate and oxygen saturation, this to ensures rapid detection of changes in clinical status and allow for accurate assessment and response to therapy.

CONCLUSION: NE is the first-line agent recommended during resuscitation of shock, but not without adverse effect.