The Tell Tale Heart

I recently received this question. This makes now the third patient who had these symptoms after an injection of Lucentis® or Avastin®.

“I received Lucentis for the fifth time. I had three in a row and then three months later one dose. After the fifth dose I became very red and my heart was racing. I went back into the doctor's office and my blood pressure had sky rocketed. They wouldn't tell me my BP until it came down to 162/80. They said Lucentis did not cause this. My BP is normal always.”

My answer:

I wrote in another blog (see Nov 28¹ and 30², 2007) about a patient who had exactly the same symptoms namely a racing heart, high blood pressure, and a pink flush. In that blog, I ascribed these symptoms to anxiety but I think I was wrong. Patients who are anxious may feel faint after an injection. A faint is called a vaso-vagal reaction and is associated with a slow pulse, low blood pressure, and clammy skin. We usually have the patient put his head down so they blood can reach the brain even with the low blood pressure and the feeling soon passes. I don’t think these patients had a typical fainting spell. They also describe the symptoms occurring after the injection when the anxiety should be decreasing.

I now think that these reactions were either due to the phenylephrine eye drops used to dilate the eye or more likely, epinephrine in the local anesthetic solution. Both of these medications can increase the heart rate and blood pressure. Epinephrine can also cause flushed skin. Epinephrine is often used in a local anesthetic injection because it constricts blood vessels. The anesthetic then will stay around at the injection site longer because it is not absorbed by the blood vessels. The constricted blood vessels will also bleed less. Eye doctors may be tempted to use epinephrine in their local anesthetic to reduce the risk of unsightly subconjunctival hemorrhage. The conjunctiva of the eye though is very vascular and will readily absorb epinephrine after its injection. Epinephrine in the blood stream causes, you guessed it, an increased heart rate, blood pressure, and flushing. We don’t use epinephrine in our local anesthetic, mainly I confess due to the intelligence of our nurses, and have not seen this reaction.

Therefore I would recommend that doctors do not use epinephrine in their local anesthetic and use just one drop of 2.5% phenylephrine to dilate the eye. Patients may want to ask the doctor or nurse to makes sure that no epinephrine is in the local anesthetic.

1. Folk JC. Query: Worried About Stroke. November 28, 2007. http://www.medrounds.org/amd/2007/11/query-worried-about-stroke.html

2. Folk JC. Anxiety and the Injection Procedure. November 30, 2008. http://www.medrounds.org/amd/2007/11/anxiety-and-injection-procedure.html