5-Aminolevulinic acid-induced severe hypotension during transurethral resection of a bladder tumor: a case report

Abstract

Background: Although 5-aminolevulinic acid (5-ALA) is used for the photodynamic diagnosis of bladder tumors, hypotension is the most commonly observed adverse effect. We present a case of 5-ALA-induced severe hypotension during transurethral resection of a bladder tumor. Case presentation: A 68-year-old man underwent transurethral resection of a bladder tumor using 5-ALA under general anesthesia. Three hours before anesthesia induction, ALA 20 mg/kg was administered orally. After anesthesia induction, his blood pressure decreased to 47/32 mmHg. Although we used phenylephrine and ephedrine, hypotension persisted at 50/33 mmHg. Bolus administration of noradrenaline slightly increased his blood pressure to 65/39 mmHg. Following this, bolus administration of adrenaline elevated his blood pressure. We decided to perform surgery under continuous administration of adrenaline. Conclusions: Our case report suggests that anesthesiologists should consider 5-ALA-induced hypotension as a differential diagnosis for hypotension occurring after anesthesia induction. Moreover, ephedrine and phenylephrine might be less effective in treating this condition.

Preanesthetic severe postural hypotension following 5-aminolevulinic acid pretreatment in patients for photodynamic diagnosis-assisted urological surgery

“…The onset time of severe hypotension in our cases was approximately 3 h after 5-ALA pretreatment, similar to a recent report [4] and seems to coincide with an increase in plasma PpIX concentration. PpIX concentration slopes upward an hour after 5-ALA pretreatment, and the 3-h concentration reaches about 3 times as high in an hour [5], indicating that substantial exogenous 5-ALA yields high concentrations of porphyrin precursors, similar to porphyria in terms of high porphyrins.…”

“…Two previous clinical studies have each listed a case with 5-ALA-related rash [1] and urticaria [3], and anaphylactic shock occurred in a patient with intravesical 5-ALA-derivative [14]. Thorough inspections for hypersensitivity may be required in severe cases [4]. According to a recent report, 5-ALA-induced hypotension may possibly be vasoactive-refractory [4].…”

“…Thorough inspections for hypersensitivity may be required in severe cases [4]. According to a recent report, 5-ALA-induced hypotension may possibly be vasoactive-refractory [4]. While severe hypotension improved in the first case, the second case suffered prolonged hypotension that continued by the next day despite continuous dopamine infusion.…”

“…This may partly explain why the characteristics, clinical course, and mechanism of 5-ALA-induced hypotension have not been fully elucidated. A recent case report described the anesthetic course of 5-ALA-induced severe hypotension that occurred immediately after the induction of general anesthesia [4]. Here, we report two cases of severe postural hypotension following 5-ALA pretreatment for transurethral resection of bladder tumor (TURBT).…”

An in vitro study of the effect of 5-ALA-mediated photodynamic therapy on oral squamous cell carcinoma

“…5-ALA-mediated photodynamic therapy can specifically kill cells or cancer cells that proliferate too fast in the tissue, without affecting normal tissues. Given that protoporphyrin IX has quick metabolism, there is no need to avoid light for a long time after treatment [5]. The current study was conducted to observe the effect of 5-ALA-mediated photodynamic therapy on OSCC in vitro, with an attempt to explore its underlying role and mechanism.…”