The clinical significance of elevated CSF and plasma histamine in cerebral aneurysm surgery utilizing cardiopulmonary bypass with total circulatory arrest

Histamine release during cardiopulmonary bypass

Plasma histamine concentrations were measured in 15 adult patients undergoing open-heart surgery (coronary artery bypass grafting) and in three control patients undergoing major noncardiac surgery. Plasma histamine levels rose in both open-heart and control patients in the early phase of operation before the onset of cardiopulmonary bypass (CPB). In the open-heart patients, significant elevations in plasma histamine concentrations occurred in the first 30 minutes of CPB (p < 0.05) in spite of haemodilution (median 36%). Plasma histamine changed neither by the application of X-clamp nor by its removal. No significant differences were observed between pulsatile and nonpulsatile flow of bypass perfusion. Two of the three patients who required infusion of sodium nitroprusside had high concentrations of plasma histamine (over 2ng/ml) throughout the observation period. DC shock induced an immediate response in histamine release. In the immediate post-CPB period when spontaneous circulation was resumed, the open-heart surgery patients exhibited a second rapid rise in plasma histamine, significantly higher than in the control patients (p < 0.05) in whom elevation in plasma histamine levels was not seen in the postoperative period. One of the CPB patients with persistent high histamine in the postoperative period had severe bronchospasm. Thus, in patients undergoing open-heart surgery, histamine release occurs at the onset of CPB and soon after the discontinuation of CPB. H1 + H2 blockade may be indicated in those at risk from histamine-mediated responses or receiving sodium nitroprusside or DC shocks.

Perioperative uses of histamine antagonists

Histamine release and adverse pseudoallergic/allergic reactions during the perioperative period occur frequently. The incidence of such reactions is 20%-30% for all grades of severity, 1%-5% for systemic reactions, and 0.1%-0.5% for life-threatening reactions. They can be elicited by all commonly used anesthetic agents and by surgical interventions. Both the incidence and severity can be reduced by the use of combined prophylaxis with H1- + H2-receptor antagonists. The authors recommend that this prophylaxis be given to the following groups of patients: those with a history of adverse reactions or history of allergy, patients undergoing surgery with a high risk of histamine release, elderly patients, and those with poor physical status due to underlying systemic diseases. These indications have been developed by heuristic medical decision-making, including a decision tree.