Anaesthetic and intensive care management of refractory hypotension in a high-risk patient with chronic cocaine use.

Chronic cocaine use is associated with complex cardiovascular changes, including catecholamine depletion and dilated cardiomyopathy, predisposing patients to peri-operative haemodynamic instability. We report a 41-year-old man with chronic cocaine use, severe left ventricular dysfunction (left ventricular ejection fraction 20%), type 2 diabetes mellitus and recent myocardial infarction who underwent emergency surgery for perforated appendicitis. After induction of anaesthesia, he developed profound hypotension refractory to fluids and ephedrine, requiring a noradrenaline infusion. The postoperative course was complicated by septic shock and acute kidney injury requiring continuous renal replacement therapy, followed by gradual stabilisation in intensive care. This case highlights that peri-operative hypotension in patients with chronic cocaine use and advanced cardiac dysfunction may reflect catecholamine depletion rather than acute intoxication. Early use of direct acting vasopressors with planned postoperative intensive care monitoring may be crucial in reducing morbidity and mortality.