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• W2320005753 abstract "To the Editor A 64-year-old woman presented for excision of a left breast cyst with preoperative placement of a radiologic marker. Her medical history was significant for right breast cancer treated by lumpectomy, hypothyroidism, ulcerative colitis, osteoporosis, migraine headaches, and anxiety. Her medications at home were levothyroxine, calcitonin, indapamide, atorvastatin, progesterone, estrogen, and lorazepam. A preoperative electrocardiogram with a rhythm strip revealed normal sinus rhythm without ectopy, and her electrolyte levels and thyroid function tests were normal. After needle localization of the cyst by a radiologist, she was brought to the operating room. She appeared anxious and fidgety, and during positioning it was noted that she was holding a Vick’s Vapor Inhaler®. She said she had used it several times in the last 2 days to clear nasal congestion and was witnessed using the inhaler several times in the preoperative waiting area. When monitors were placed, the patient was found to have a blood pressure of 188/88 mm Hg, a heart rate of 78 bpm, and normal sinus rhythm but with frequent unifocal premature ventricular contractions and 3-beat to 6-beat runs of ventricular tachycardia. Since the radiologic marker was already in place, we decided to proceed with surgery under sedation with propofol (total 160 mg) and local anesthesia (an equal mixture of 0.5% bupivacaine and 1% lidocaine without epinephrine). The procedure lasted 20 minutes and although no specific antidysrhythmic therapy was administered, the frequency of ectopy decreased while the patient was sedated. She was monitored in the postanesthesia care unit for 2 hours where she initially had frequent premature ventricular contractions and 3-beat runs of ventricular tachycardia. Her blood pressure was stable at 140/60 mm Hg, and her heart rate was consistently in the 70s. When her ectopy decreased to single premature ventricular contractions occurring at a rate of less than 5 per minute she was discharged home and advised to discontinue use of the Vick’s Vapor Inhaler. The active ingredient in the Vick’s Vapor Inhaler sold in the United States is “levmetamfetamine,” also known as levomethamphetamine or L -methamphetamine. It acts as a nasal decongestant via α-adrenergic agonism. Methamphetamine is a central nervous system and cardiovascular stimulant. Of its 2 enantiomers, D-methamphetamine is a stronger central nervous system stimulant, produces more pleasurable psychoactive effects, and has more abuse potential.1 The L-enantiomer has less abuse potential, so it is available over the counter. The degree of cardiovascular stimulation by L-methamphetamine is also less than that of D-methamphetamine, but because the half-life of L -methamphetamine is long (13 hours), it may accumulate with repeated dosing.1 The package insert states that an 800 µL nasal inhalation delivers between 0.04 mg and 0.15 mg of L -methamphetamine. The recommended dosing interval is every 2 hours, as needed. We believe that repeated dosing of L-methamphetamine caused hypertension, tachycardia, and ventricular ectopy that gradually resolved over time. Excessive use of the Vick’s Vapor Inhaler has been reported to produce uncomfortable nasal and oral dryness followed by rebound congestion of the nasal passages, but perioperative hemodynamic alterations as seen in this patient have not previously been reported.2 Although anxiety may have also been a contributing factor, the patient had no history of palpitations associated with anxiety and no history of dysrhythmias. Indapamide has been reported to cause ventricular dysrhythmias, but the mechanism was hypokalemia and QT interval prolongation.3,4 This patient had neither. Patient Consent Statement: The patient gave her consent to publication of this report. Laura Morello, MD Thomas J. Martin, MD Department of Anesthesiology The University of Connecticut School of Medicine, Farmington, Connecticut [email protected]" @default.
• W2320005753 created "2016-06-24" @default.
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• W2320005753 date "2013-02-01" @default.
• W2320005753 modified "2023-10-18" @default.
• W2320005753 title "Hypertension and Ventricular Tachycardia with Perioperative Use of Vick’s Vapor Inhaler®" @default.
• W2320005753 cites W2004463976 @default.
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• W2320005753 doi "https://doi.org/10.1213/ane.0b013e3182798986" @default.
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