Exaggerated hemodynamic responses to nasal injection and awakening from anesthesia in a Cushingoid patient having transsphenoidal hypophysectomy

A 51-year-old female patient, with an adrenocorticotrophic hormone-secretin g pituitary tumor, was scheduled for transphenoidal hypophysectomy. She had a history of recent onset diabetes mellitus and a 2-year history of arteri al hypertension. Despite ongoing medical therapy, preoperative blood pressu re was 150-160/9-120 mm Ng. During general anesthesia, in response to perin asal infiltration with 10 mi of a solution containing lidocaine 200 mg and epinephrine 100 mu g, blood pressure increased from 144/80 mm Hg to 317/175 over 3 minutes, as assessed by direct blood pressure monitoring. At the co mpletion of the anesthetic, as the patient awakened and coughed and moved, blood pressure again increased dramatically, this time from 154/87 mm Hg to 285/170 over 3 minutes. Five months postoperatively, the patient's serum c ortisol concentrations had normalized and her cuff blood pressure was 126/8 2, despite a reduction in her antihypertensive medications. The dramatic in traoperative blood pressure changes in this patient were attributed to the effects of hypercortisolemia on the normal physiologic responses to epineph rine and patient movement.