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Epidural-Related Hypotension — FRCA Final MCQ

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ModerateGeneral AnaesthesiaEpidural-Related HypotensionFRCA Final

A 65-year-old man, ASA III, is undergoing anterior resection under general anaesthesia with a T9/10 epidural. The epidural contains bupivacaine 0.125% with fentanyl 2 micrograms/mL and is running at 8 mL/hour. His blood pressure, previously 135/75 mmHg, falls to 75/40 mmHg. His heart rate is 82 beats/min in sinus rhythm; oxygen saturation, airway pressures and end-tidal carbon dioxide are unchanged. The surgical field is dry, and there is no rash, bronchospasm or other evidence of anaphylaxis. Which is the most appropriate immediate haemodynamic treatment?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Give a titrated intravenous vasopressor with a 250–500 mL crystalloid bolus

The correct answer is A. Severe hypotension during combined general and epidural anaesthesia requires prompt restoration of perfusion while reversible causes are reassessed. Epidural local anaesthetic produces sympathetic blockade, reducing arteriolar and venous tone, and general anaesthetic agents compound the vasodilatation. The UK SmPC for bupivacaine directs treatment of cardiovascular depression with intravenous fluids and vasopressor/inotropic agents, and prompt sympathomimetic therapy for hypotension. A titrated vasopressor (metaraminol, phenylephrine or ephedrine, guided by heart rate) corrects pressure fastest; a cautious 250–500 mL crystalloid bolus addresses relative hypovolaemia without fluid-overloading an ASA III patient with COPD. Stopping the epidural (B) will not rapidly reverse an established block and leaves the hypotension untreated for 10 minutes. Adrenaline 1 mg (C) is a cardiac-arrest dose and dangerous here. Transfusion (D) is unsupported with a dry field and no evidence of haemorrhage, and pulmonary artery catheterisation (E) delays essential treatment.

Reference: Electronic Medicines Compendium (eMC). Bupivacaine Hydrochloride 0.25% w/v solution for injection — Summary of Product Characteristics, sections 4.4/4.9 (treatment of cardiovascular depression with IV fluids and vasopressors). https://www.medicines.org.uk/emc/product/13990/smpc