Refractory Hypotension after Tourniquet Deflation in a Patient on Chronic Clomipramine Therapy

Abstract

Treatment of intraoperative hypotension in a patient on chronic tricyclic antidepressant therapy(TCA) is contro-versial. Evidence based guidelines for the management of psychotropic drugs during perioperative period are lacking. We present a patient who was subjected to bilateral total knee replacement under combined spinal epidural anaesthe-sia. She developed refractory hypotension after release of tourniquet and responded only to large dosage of norepi-nephrine along with acid base correction. We believe that chronic TCA therapy led to depleted catecholamine re-serves and down regulation of its receptors. Release of tourniquet led to metabolic acidosis and subsequently in-creased free clomipramine concentration in blood leading to severe refractory hypotension.

Keywords

• Tricyclic antidepressants
• hypotension
• clomipramine
• tourniquet deflation
• combined spinal epidural anaesthesia