Background: NE is an  1 and  1 agonist, used for its arterial, venous vasoconstrictor and positive inotropic properties.[1] However, accidental IV NE is known to result in serious cardiovascular side effects which may include hypertension, angina, arrhythmia, acute myocardial infarction (AMI) and ventricular fibrillation with cardiac arrest.[2,3]
Case Report: A 52-year-old male patient was proposed for elective excision of an hemangiopericytoma (HPC). Previous medical history included an appendectomy. Preoperative anesthetic evaluation revealed no prediction of a difficult airway. ASA class II. Anthropometric parameters: Weight: 80 Kg; Height: 1,75 cm; BMI: 26,1 Kg/m2.
Anaesthesic approach:The patient induction was started using fentanyl 0,15 mg, propofol 160 mg and rocuronium 50 mg. Maintenance was accomplished with sevoflurane (MAC 1.5) + 02 + air; perfusions of rocuronium (2 mg/mL) 16 mL/h, remifentanil (50 mcg/mL) 0,05-2 mcg/Kg/min and norepinephrine (200 mcg/mL) 0,025-0,1 mcg/Kg/min. Upon final stages of surgery, as perfusions were stopped an accidental administration of 1 mg of NE occured. Shortly thereafter, he developed supraventricular tachycardia up to 190 beats per minute and arterial hypertension (205/110 mmHg). Electrocardiographic (ECG) recording showed signs of myocardial ischemia including ST-segment elevation in the D2 and V5 leads. Afterwards, arterial pressure dropped abruptly to 80/40 mm Hg and arterial blood gases showed moderate acidosis, hypocapnia with hypoxemia. The surgery was finished and the patient was then admitted in the intensive care unit (ICU). ECG recording revealed no alterations compatible with ischemia nor AMI. Cardiac biomarkers were within normal range and no signs of congestion were identified in chest X-ray. Patient was then extubated uneventfully. Discharge with the patient in stable condition occurred past 6 days.
Discussion: This clinical pattern was similar to cases of NE overdose previously described in the literature.[1]  Despite uncommon, it highlights the importance of independent double-checking and strict signing of all medications before administration. Early recognition and support treatment are crucial to avoid fatal outcomes.
Learning Points:Despite all the anesthesiology evolution in the past decades, it is vital to always assure the patient safety in order to diminish the occurrence of avoidable errors.
References:
[1] Ibbey AA, et al. Inadvertent overinfusion of norepinephrine using infusion pump loading dose. Intensive Crit Care Nurs 2015 Dec;31(6):375-9.
[2] Arfi AA, et al. Acute myocardial ischemia following accidental intravenous administration of epinephrine in high concentration. Indian Heart J 2005;57:261-264.
[3] Ahmed DB, et al. Intraoperative Ventricular Fibrillation Arrest Caused by Accidental Intravenous Injection of Epinephrine. Ibnosina J Med BS 2014;6(5):223-226.

03 / Severe reaction to inadvertent intravenous administration of norepinephrine