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Pouessel G, Dribin TE, Tacquard C, Tanno LK, Cardona V, Worm M, Deschildre A, Muraro A, Garvey LH, Turner PJ. Management of Refractory Anaphylaxis: An Overview of Current Guidelines. Clin Exp Allergy 2024. [PMID: 38866583 DOI: 10.1111/cea.14514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 06/14/2024]
Abstract
In this review, we compare different refractory anaphylaxis (RA) management guidelines focusing on cardiovascular involvement and best practice recommendations, discuss postulated pathogenic mechanisms underlining RA and highlight knowledge gaps and research priorities. There is a paucity of data supporting existing management guidelines. Therapeutic recommendations include the need for the timely administration of appropriate doses of aggressive fluid resuscitation and intravenous (IV) adrenaline in RA. The preferred second-line vasopressor (noradrenaline, vasopressin, metaraminol and dopamine) is unknown. Most guidelines recommend IV glucagon for patients on beta-blockers, despite a lack of evidence. The use of methylene blue or extracorporeal life support (ECLS) is also suggested as rescue therapy. Despite recent advances in understanding the pathogenesis of anaphylaxis, the factors that lead to a lack of response to the initial adrenaline and thus RA are unclear. Genetic factors, such as deficiency in platelet activating factor-acetyl hydrolase or hereditary alpha-tryptasaemia, mastocytosis may modulate reaction severity or response to treatment. Further research into the underlying pathophysiology of RA may help define potential new therapeutic approaches and reduce the morbidity and mortality of anaphylaxis.
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Affiliation(s)
- Guillaume Pouessel
- Department of Paediatrics, Children's Hospital, Roubaix, France
- Paediatric Pulmonology and Allergy Department, Jeanne de Flandre Hospital, CHU Lille, Lille, France
- Univ Lille, ULR 2694: METRICS, Lille, France
| | - Timothy E Dribin
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Charles Tacquard
- Department of Anaesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Luciana Kase Tanno
- University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, University of Montpellier - INSERM, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Victoria Cardona
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Berlin, Germany
| | - Antoine Deschildre
- Paediatric Pulmonology and Allergy Department, Jeanne de Flandre Hospital, CHU Lille, Lille, France
| | - Antonella Muraro
- Food Allergy Referral Centres, Padua University Hospital, Padua, Italy
| | - Lene H Garvey
- Department of Dermatology and Allergy, Danish Anaesthesia Allergy Centre, Allergy Clinic, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, UK
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Nakai T, Kako E, Ota H, So M, Sobue K. Remimazolam anaphylaxis in a patient not allergic to brotizolam: a case report and literature review. BMC Anesthesiol 2024; 24:204. [PMID: 38851690 PMCID: PMC11161983 DOI: 10.1186/s12871-024-02591-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 06/03/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND Remimazolam is a recently developed, ultrashort-acting benzodiazepine that is used as a general anesthetic. Some cases of remimazolam anaphylaxis have been reported, but its characteristics are not fully understood. We present an interesting case report and review of the literature to better understand remimazolam anaphylaxis. CASE PRESENTATION A 75-year-old man scheduled for robot-assisted gastrectomy was administered remimazolam for the induction of general anesthesia. After intubation, low end-expiratory CO2, high airway pressure and concurrent circulatory collapse were observed. Bronchoscopy revealed marked tracheal and bronchial edema, which we diagnosed as anaphylaxis. The patient suffered cardiac arrest after bronchoscopy but recovered immediately with intravenous adrenaline administration and chest compressions. We performed skin prick tests for the drugs used during induction except for remimazolam, considering the high risk of systemic adverse reactions to remimazolam. We diagnosed remimazolam anaphylaxis because the skin prick test results for the other drugs used during anesthesia were negative, and these drugs could have been used without allergic reactions during the subsequent surgery. Furthermore, this patient had experienced severe anaphylactic-like reactions when he underwent cardiac surgery a year earlier, in which midazolam had been used, but it was not thought to be the allergen at that time. Based on these findings, cross-reactivity to remimazolam and midazolam was suspected. However, the patient had previously received another benzodiazepine, brotizolam, to which he was not allergic, suggesting that cross-reactivity of remimazolam may vary among benzodiazepines. In this article, we reviewed the 11 cases of remimazolam anaphylaxis that have been described in the literature. CONCLUSIONS Remimazolam is an ultrashort-acting sedative; however, it can cause life-threatening anaphylaxis. In addition, its cross-reactivity with other benzodiazepines is not fully understood. To increase the safety of this drug, further research and more experience in its use are needed.
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Affiliation(s)
- Toshihiro Nakai
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-Ku 467-8601, Nagoya, Japan
| | - Eisuke Kako
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-Ku 467-8601, Nagoya, Japan.
| | - Haruko Ota
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-Ku 467-8601, Nagoya, Japan
| | - MinHye So
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-Ku 467-8601, Nagoya, Japan
| | - Kazuya Sobue
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-Ku 467-8601, Nagoya, Japan
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Dodd A, Turner PJ, Soar J, Savic L. Emergency treatment of peri-operative anaphylaxis: Resuscitation Council UK algorithm for anaesthetists. Anaesthesia 2024; 79:535-541. [PMID: 38205901 DOI: 10.1111/anae.16206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2023] [Indexed: 01/12/2024]
Abstract
Peri-operative anaphylaxis is a rare but potentially catastrophic event which must be considered whenever unexpected and significant cardiovascular or respiratory compromise occurs during anaesthesia. The Resuscitation Council UK algorithm for peri-operative anaphylaxis highlights the importance of early intravenous adrenaline and fluid resuscitation and provides guidance on the treatment of refractory anaphylaxis and immediate follow-up. This algorithm is endorsed by the Royal College of Anaesthetists, Association of Anaesthetists, British Society of Allergy and Clinical Immunology and Clinical Immunology Professional Network of the British Society for Immunology. This document was produced by the Perioperative Allergy Network steering committee in collaboration with the Resuscitation Council UK.
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Affiliation(s)
- A Dodd
- Department of Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - P J Turner
- Department of Paediatric Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College, London, UK
| | - J Soar
- Department of Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - L Savic
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Tran R, Pedersen K, Kolawole H, Roessler P, Scolaro R. Australian and New Zealand Anaesthetic Allergy Group/Australian and New Zealand College of Anaesthetists perioperative anaphylaxis management guideline 2022. Anaesth Intensive Care 2024; 52:147-158. [PMID: 38587791 DOI: 10.1177/0310057x231215823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Perioperative anaphylaxis is a potentially life-threatening emergency that requires prompt recognition and institution of life-saving therapy. The Australian and New Zealand College of Anaesthetists and Australian and New Zealand Anaesthetic Allergy Group have partnered to develop the anaphylaxis management guideline along with crisis management cards that are recommended for use in suspected anaphylaxis in the perioperative setting. This is the third version of these guidelines with the second version having been published in 2016. This article contains the revised Australian and New Zealand Anaesthetic Allergy Group/Australian and New Zealand College of Anaesthetists perioperative anaphylaxis management guideline, with a brief review of the current evidence for the management of anaphylaxis in the perioperative environment.
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Affiliation(s)
- Robyn Tran
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Karen Pedersen
- Department of Anaesthesia and Perioperative Medicine, Te Toka Tumai, Auckland, New Zealand
| | - Helen Kolawole
- Department of Anaesthesia, Peninsula Health, Victoria, Australia
- Anaesthesia Teaching and Research, Monash University, Melbourne, Australia
| | - Peter Roessler
- Australian and New Zealand College of Anaesthetists, Melbourne Victoria, Australia
| | - Richard Scolaro
- Department of Anaesthesia, Sunshine Coast University Hospital, Sunshine Coast, Australia
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Cherrez-Ojeda I, Gallardo-Bastidas JC, Borrero GR, Mautong H, Silva PAM, Sarfraz Z, Sarfraz A, Cano L, Robles-Velasco K. Knowledge and attitudes toward anaphylaxis to local anesthetics in dental practice. BDJ Open 2024; 10:28. [PMID: 38575579 PMCID: PMC10994913 DOI: 10.1038/s41405-024-00210-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/18/2024] [Accepted: 03/18/2024] [Indexed: 04/06/2024] Open
Abstract
OBJECTIVE/AIM The absence of a comprehensive understanding of potential anaphylactic reactions to local anesthetics (LAs) and management can result in grave consequences. For this reason we aim to assess Latin American dentists' knowledge, preparedness, and competency in managing anaphylactic reactions to LAs. MATERIALS AND METHODS Design: A cross-sectional study was conducted from November 2021 to February 2022. Board-certified dentists answered a survey comprising 26 structured questions. Chi-square tests and logistic regression models were performed in Stata 17.0. SETTING Argentina, Brazil, Colombia, Costa Rica, Ecuador, Honduras, Mexico, Peru, Venezuela, and other Latin American countries. RESULTS Of 507 respondents, lidocaine was the most frequently used LA (88.1%). While 85.2% could identify dyspnea as a symptom of anaphylaxis, only 50.1% knew the correct route for epinephrine administration, and just 43.5% had epinephrine in their emergency kits. Confidence in managing anaphylactic reactions was low (9.6%). Older age was inversely related to both knowledge of anaphylaxis management and the possession of epinephrine (P = 0.003 and P = 0.0001, respectively). DISCUSSION Our study highlights a concerning discrepancy between the practical readiness of Latin American dentists in handling anaphylaxis. CONCLUSION The study's findings underscore the need for educational interventions to improve the readiness to identify and handle anaphylactic emergencies in dental practice.
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Affiliation(s)
- Ivan Cherrez-Ojeda
- Universidad Espíritu Santo, Samborondón, 0901952, Ecuador.
- Respiralab, Respiralab Research Group, Guayaquil, Ecuador.
| | - Juan C Gallardo-Bastidas
- Universidad Católica de Santiago de Guayaquil Carrera de Odontología, Guayaquil, 09-01-4671, Ecuador
| | | | - Hans Mautong
- Universidad Espíritu Santo, Samborondón, 0901952, Ecuador
- Respiralab, Respiralab Research Group, Guayaquil, Ecuador
| | | | - Zouina Sarfraz
- Department of Research and Publications, Fatima Jinnah Medical University, Lahore, PB, Pakistan
| | - Azza Sarfraz
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, P.O Box 3500, Karachi, 74800, Pakistan
| | - Leonardo Cano
- Respiralab, Respiralab Research Group, Guayaquil, Ecuador
| | - Karla Robles-Velasco
- Universidad Espíritu Santo, Samborondón, 0901952, Ecuador
- Respiralab, Respiralab Research Group, Guayaquil, Ecuador
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Özdemir Ö. Comment on Beneki E, Dimitriadis K, Antonopoulos A, Aggeli K & Tsioufis K. Kounis syndrome due to remdesivir allergy. Clin Toxicol (Phila) 2024; 62:274-275. [PMID: 38655636 DOI: 10.1080/15563650.2024.2331621] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/13/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Öner Özdemir
- Division of Allergy and Immunology, Department of Pediatrics, Research and Training Hospital of Sakarya University Medical Faculty, Adapazarı, Sakarya, Türkiye
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Suzuki Y, Liu S, Yamashita N, Yamaguchi N, Takasaki Y, Yorozuya T, Mogi M. Perioperative Anaphylaxis in Japanese Secondary Care Institutions: Incidence, Causes, and the Imperative for Improved Diagnostic Practices. Cureus 2024; 16:e57555. [PMID: 38707122 PMCID: PMC11068509 DOI: 10.7759/cureus.57555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Background This research investigates the incidence, suspected causes, and diagnostic procedures for perioperative anaphylaxis (POA), a potentially severe complication, in secondary care hospitals across Japan. Methodology We surveyed Saiseikai hospitals and gathered data on surgical procedures, POA occurrences, potential triggers, and diagnostic methods. Results Among 70,523 surgeries, seven were associated with POA, resulting in an approximate incidence rate of 0.01%. Rocuronium was the most commonly suspected trigger, followed by sugammadex, latex, and angiography contrast agents. Despite the importance of skin tests as the most basic and crucial diagnostic method, they were conducted in only three instances. No in vitro tests for drug identification were conducted, and in four cases, the cause was determined merely based on the timing of drug administration, indicating significant diagnostic limitations. Conclusions The study underscores the critical situation in Japan regarding insufficient diagnostic practices and difficulties in identifying triggering drugs rather than the consistent prevalence of POA in secondary care facilities. The findings emphasize the need for improved diagnostic proficiency and more rigorous drug identification practices to ensure prompt and accurate POA diagnosis. It is essential to conduct further research and interventions to increase patient safety during the perioperative period in secondary care settings.
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Affiliation(s)
- Yasuyuki Suzuki
- Anesthesiology, Saiseikai Matsuyama Hospital, Matsuyama, JPN
- Research Division, Saiseikai Research Institute of Health Care and Welfare, Tokyo, JPN
- Department of Pharmacology, Ehime University Graduate School of Medicine, Toon, JPN
| | - Shuang Liu
- Department of Pharmacology, Ehime University Graduate School of Medicine, Toon, JPN
| | - Natsumi Yamashita
- Clinical Research Center, National Hospital Organization Shikoku Cancer Center, Matsuyama, JPN
| | - Naohito Yamaguchi
- Research Division, Saiseikai Research Institute of Health Care and Welfare, Tokyo, JPN
| | - Yasushi Takasaki
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, JPN
| | - Toshihiro Yorozuya
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, JPN
| | - Masaki Mogi
- Department of Pharmacology, Ehime University Graduate School of Medicine, Toon, JPN
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Mitchell W, Moses M, Tolman A, Endsley D, Ok J, Jeyarajah R. Sustained intraoperative allergic reaction to chlorhexidine: A case report. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100201. [PMID: 38283771 PMCID: PMC10820793 DOI: 10.1016/j.jacig.2023.100201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/30/2023] [Accepted: 09/05/2023] [Indexed: 01/30/2024]
Abstract
Physicians should be prepared for the presentation and treatment of an anaphylactic reaction in a patient who has been exposed to chlorhexidine perioperatively and consider a sustained source of allergic exposure when faced with a refractory response to treatment.
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Affiliation(s)
- William Mitchell
- Burnett School of Medicine at Texas Christian University, Fort Worth, Tex
| | - Morgan Moses
- Burnett School of Medicine at Texas Christian University, Fort Worth, Tex
| | - Alex Tolman
- Burnett School of Medicine at Texas Christian University, Fort Worth, Tex
| | - Dakota Endsley
- Burnett School of Medicine at Texas Christian University, Fort Worth, Tex
| | - John Ok
- Burnett School of Medicine at Texas Christian University, Fort Worth, Tex
- Methodist Richardson Medical Center, Richardson, Tex
| | - Rohan Jeyarajah
- Burnett School of Medicine at Texas Christian University, Fort Worth, Tex
- Methodist Richardson Medical Center, Richardson, Tex
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Horiuchi T, Takazawa T. Perioperative anaphylaxis with no identifiable cause. JA Clin Rep 2024; 10:3. [PMID: 38253957 PMCID: PMC10803722 DOI: 10.1186/s40981-024-00688-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Affiliation(s)
- Tatsuo Horiuchi
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511, Japan
| | - Tomonori Takazawa
- Department of Anesthesiology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan.
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Hirai S, Ida M, Arima A, Kawaguchi M. Suspected anaphylaxis during anesthesia induction without identified allergens: a case report. JA Clin Rep 2023; 9:89. [PMID: 38108931 PMCID: PMC10728379 DOI: 10.1186/s40981-023-00684-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/28/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023] Open
Affiliation(s)
- Sayaka Hirai
- Department of Anaesthesiology, Nara Medical University, Kashihara, Nara, Japan
| | - Mitsuru Ida
- Department of Anaesthesiology, Nara Medical University, Kashihara, Nara, Japan.
| | - Ai Arima
- Department of Dermatology, Nara Medical University, Kashihara, Nara, Japan
| | - Masahiko Kawaguchi
- Department of Anaesthesiology, Nara Medical University, Kashihara, Nara, Japan
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Ishii T, Miyoshi H, Kubo T, Tsutsumi YM, Horikawa YT, Tanaka H. Delayed Nonimmune Anaphylaxis Caused by Ropivacaine for Preoperative Nerve Blocks: A Case Report. A A Pract 2023; 17:e01727. [PMID: 37948548 DOI: 10.1213/xaa.0000000000001727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Ropivacaine is an amide local anesthetic with rare reports of anaphylaxis. To our knowledge, this is the first report of delayed nonimmune anaphylaxis induced by ropivacaine. A 70-year-old man underwent general anesthesia with a nerve block for a total knee arthroplasty. The patient developed symptoms of anaphylaxis 3.5 hours after receiving ropivacaine for femoral and tibial nerve blocks. A basophil activation test (BAT) revealed ropivacaine as the causative agent. Notably, anaphylaxis can be caused by medications even hours after their administration, and all administered drugs should be suspected of potentially causing anaphylaxis.
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Affiliation(s)
- Tomomi Ishii
- From the Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima, Japan
| | - Hirotsugu Miyoshi
- From the Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima, Japan
| | - Takashi Kubo
- Department of Anesthesiology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Yasuo M Tsutsumi
- From the Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima, Japan
| | - Yousuke T Horikawa
- Department of Pediatrics, Sharp Rees-Stealy Medical Group, San Diego, California
| | - Hiroyuki Tanaka
- Department of Anesthesiology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
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Ichinomiya T, Sekino M, Toba M, Yokoyama A, Iwasaki N, Kasai Y, Araki H, Yano R, Matsumoto S, Kurobe M, Sasaki R, Hara T. Refractory cardiac arrest caused by type I Kounis syndrome treated with adrenaline and nicorandil: A case report. Medicine (Baltimore) 2023; 102:e34535. [PMID: 37565887 PMCID: PMC10419590 DOI: 10.1097/md.0000000000034535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/10/2023] [Indexed: 08/12/2023] Open
Abstract
RATIONALE Kounis syndrome is a rare but life-threatening anaphylactic reaction that can lead to acute coronary syndrome and cardiac arrest, and requires prompt diagnosis. Adrenaline, which is used to treat anaphylaxis, may cause coronary vasoconstriction and worsen ischemia, whereas coronary vasodilators may dilate systemic vessels and exacerbate hypotension. Delayed diagnosis of Kounis syndrome and inadequate therapeutic intervention may thus lead to a poor outcome. PATIENT CONCERNS A 59-year-old man was treated for sepsis due to a liver abscess. Following administration of daptomycin, the patient developed severe anaphylactic shock leading to refractory cardiac arrest. Because conventional cardiopulmonary resuscitation was ineffective, extracorporeal cardiopulmonary resuscitation was considered as an alternative approach. DIAGNOSES On bedside monitoring during cardiopulmonary resuscitation, unexpected ST-segment elevation was found on lead II electrocardiogram. Accordingly, the patient was clinically diagnosed with Kounis syndrome. INTERVENTIONS Nicorandil (6 mg/h), a coronary vasodilator with minimal blood pressure effects, was administered along with high doses of vasopressors, including adrenaline 0.2 µg/kg/min. OUTCOMES After the initiation of nicorandil administration, the patient achieved return of spontaneous circulation and did not require extracorporeal cardiopulmonary resuscitation. Based on the elevated serum tryptase level, normal creatine kinase-MB range, and lack of stenosis on coronary angiography, the patient was definitively diagnosed with type I (coronary vasospasm) Kounis syndrome. He was subsequently transferred to the referring hospital without neurological sequelae. LESSONS If anaphylaxis leads to refractory shock and cardiac arrest, ischemic changes on the electrocardiogram should be investigated to identify underlying Kounis syndrome. In addition to adrenaline, coronary dilators are the definitive treatment. Nicorandil may be a useful treatment option because of its minimal effect on blood pressure.
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Affiliation(s)
- Taiga Ichinomiya
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Motohiro Sekino
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Megumi Toba
- Department of Anesthesia, Sasebo City General Hospital, Nagasaki, Japan
| | - Akihiro Yokoyama
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Naoya Iwasaki
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yusuke Kasai
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroshi Araki
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Rintaro Yano
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Sojiro Matsumoto
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaya Kurobe
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ryu Sasaki
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Mertes PM, Tacquard C. Perioperative anaphylaxis: when the allergological work-up goes negative. Curr Opin Allergy Clin Immunol 2023; 23:287-293. [PMID: 37357801 DOI: 10.1097/aci.0000000000000912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
PURPOSE OF REVIEW Perioperative anaphylaxis (POA) is rare but is associated with significant morbidity and mortality. Patients are referred to the allergist to identify the mechanism of the reaction, the causative agent and make recommendations regarding subsequent anaesthesia. Despite a well conducted allergological evaluation, the causative agent is not found in 30-60% of these reactions, leaving patients without a well established diagnosis. RECENT FINDINGS Several mechanisms can induce POA. In addition to the well known IgE-mediated reactions, IgG-mediated reaction, MRGPR-X2-related reaction or nonspecific histamine release may be involved. These situations are not easily assessed by the allergological workup. SUMMARY When the allergological workup is negative, the situation should be reassessed with the team present at the time of the reaction to confirm the reality of the hypersensitivity reaction and to search for a possible differential diagnosis. If POA is confirmed, the allergological evaluation should be repeated, ensuring proper execution according to current guidelines and including the search for hidden allergens. Specific IgE assays or basophil activation tests may be of interest. In case of negative results, a closely monitored drug challenge test, in coordination with the anaesthesia teams, may be useful to avoid the exclusion of any drug injected during the reaction.
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Affiliation(s)
- Paul-Michel Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Team EFS-INSERM U1255, EFS Grand-Est, Strasbourg, France
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Suzuki Y, Liu S, Iwata M, Yamamoto H, Nishida K. Ondansetron-Induced Anaphylactic Shock: An In-Depth Analysis of a Rare Adverse Event. Cureus 2023; 15:e42894. [PMID: 37664335 PMCID: PMC10474905 DOI: 10.7759/cureus.42894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Ondansetron, a drug predominantly employed in most general anesthesia cases, is critical for mitigating postoperative nausea and vomiting prompted by anesthetics. Although infrequent side effects such as serotonin syndrome are recognized, the drug is generally acknowledged for its safety. Nonetheless, some reports showed cases of anaphylactic shock associated with ondansetron. In this context, we have meticulously analyzed an anaphylactic case triggered by ondansetron that we encountered. Our deep-dive investigation suggests that the reaction might not be a traditional type I allergic reaction, typically associated with the drug. Instead, we present the possibility that the response could be mediated through Mas-related G protein-coupled receptor X2 (MRGPRX2), a divergent pathway leading to comparatively milder symptoms of anaphylaxis. In addition to the crucial role of adrenaline in unstable hemodynamics, our case highlights the effective use of antihistamines in rapidly managing such reactions. This finding suggests a need to further examine the safety profiles of common drugs like ondansetron and the potential involvement of MRGPRX2 in drug-induced hypersensitivity reactions.
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Affiliation(s)
- Yasuyuki Suzuki
- Anesthesiology, Saiseikai Matsuyama Hospital, Matsuyama, JPN
| | - Shuang Liu
- Pharmacology, Ehime University Graduate School of Medicine, Toon, JPN
| | - Mari Iwata
- Dermatology, Ehime Prefectural Central Hospital, Matsuyama, JPN
| | | | - Katsuko Nishida
- Anesthesiology, Saiseikai Matsuyama Hospital, Matsuyama, JPN
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Horiuchi T, Takazawa T, Haraguchi T, Orihara M, Nagumo K, Saito S. Investigating the optimal diagnostic value of histamine for diagnosing perioperative hypersensitivity: a prospective, observational study. J Anesth 2023:10.1007/s00540-023-03199-z. [PMID: 37156974 DOI: 10.1007/s00540-023-03199-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/29/2023] [Indexed: 05/10/2023]
Abstract
Although several guidelines recommend measuring blood tryptase and histamine concentrations to diagnose perioperative anaphylaxis (POA), tryptase measurement is more common. The appropriate timing of blood collection and the diagnostic threshold for histamine measurement are still controversial. To address these issues, histamine concentrations in patients with anaphylaxis and those with anaphylaxis-uncertain were compared in our previous study, the Japanese Epidemiologic Study for Perioperative Anaphylaxis (JESPA). However, because we could not rule out the possibility that the anaphylactic-uncertain group included anaphylactic patients, histamine concentrations were measured in patients who underwent general anesthesia with no complications as controls in the present study. Histamine levels were measured at anesthesia induction (baseline), 30 min (first point), and 2 h (second point) after the start of surgery in 30 control patients. Histamine concentrations in controls were lower than in patients with POA in JESPA at the first and second points. At the first point, a threshold of 1.5 ng/ml resulted in sensitivity of 77% and specificity of 100%. A threshold of 1.1 ng/ml at the second point resulted in sensitivity of 67% and specificity of 87%. Measurement of histamine concentrations within two hours after symptom onset might help diagnose POA.
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Affiliation(s)
- Tatsuo Horiuchi
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Tomonori Takazawa
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371-8511, Japan.
| | - Takashi Haraguchi
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Masaki Orihara
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Kazuhiro Nagumo
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Shigeru Saito
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
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Iwakiri M, Inoue R, Uchida K. Allergic reactions to propofol in adult patients with egg or soybean allergy: a retrospective cohort study from a large database of a single institute. JA Clin Rep 2023; 9:1. [PMID: 36617591 PMCID: PMC9826766 DOI: 10.1186/s40981-022-00591-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/17/2022] [Accepted: 12/21/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND In recent years, many reports have indicated that propofol is safe to administer to patients with egg/soybean allergy in Western countries. Egg allergy is more frequent in Asia, but there are limited reports regarding allergic reactions to propofol use among adults. This study aimed to determine whether propofol causes allergic reactions in patients with egg/soybean allergy. METHODS Adult patients who underwent surgery involving anesthesiologists from 2018 to 2021 were included. In all patients, we reviewed food allergy information in their electronic medical record and extracted anesthetics. Patients with egg/soybean allergy were subdivided into two groups on the basis of intraoperative use of propofol. We evaluated each group for allergic reactions within 24 h after the induction of anesthesia. The primary outcome was a relative risk of allergic reactions after propofol use for patients with egg/soybean allergy. RESULTS In total, 22,111 patients with 28,710 anesthesia records were identified. Among patients with egg/soybean allergy, 173 (0.8%) patients and 237 (0.8%) anesthesia records were included in the study. Among the records of egg-/soybean-allergic patients, 151 were administered propofol, and 86 were not. The relative risk of allergic reactions after propofol use for patients with egg/soybean allergy was 1.14 (95% confidence interval, 0.10-12.4; p = 0.74). CONCLUSION The use of propofol in patients with egg/soybean allergy does not significantly increase the relative risk of allergic reactions. Therefore, anesthesiologists can appropriately determine the indication for propofol, even in patients with egg/soybean allergy. TRIAL REGISTRATION UMIN-CTN, UMIN000049321 registered 26 October 2022 - retrospectively registered, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000056167.
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Affiliation(s)
- Masaki Iwakiri
- grid.412708.80000 0004 1764 7572Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Reo Inoue
- grid.412708.80000 0004 1764 7572Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Kanji Uchida
- grid.412708.80000 0004 1764 7572Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
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17
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Shu A, Hoshi T, Hagiya K. Anaphylaxis in the operating room treated with an anaphylaxis response kit: A case report. Saudi J Anaesth 2023; 17:117-119. [PMID: 37032664 PMCID: PMC10077791 DOI: 10.4103/sja.sja_631_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 12/24/2022] Open
Abstract
Anaphylaxis is a rapidly fatal complication of anesthesia, and it needs to be appropriately diagnosed and treated by anesthesiologists. A 37-year-old man underwent surgery for pneumothorax under general anesthesia. Postoperatively, the train-of four count was four, and sugammadex was administered. Soon after, the patient's oxygen saturation and blood pressure decreased, and skin flushing was noted. We suspected anaphylaxis and administered adrenaline. Once the blood pressure normalized, we administered hydrocortisone, famotidine, and d-chlorpheniramine maleate. Thereafter, his condition stabilized, he recovered well, and he was discharged. Blood samples obtained after the onset of the episode indicated anaphylaxis, and a prick test performed 10 weeks postoperatively confirmed sugammadex as the causative agent. We report a case of sugammadex-induced anaphylaxis, which we could properly diagnose and treat because an anaphylaxis kit was available in our department.
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Affiliation(s)
- Akae Shu
- Department of Anesthesiology and Critical Care Medicine, Ibaraki Prefectural Central Hospital, Kasama, Ibaraki, Japan
| | - Takuo Hoshi
- Department of Anesthesiology and Critical Care Medicine, Ibaraki Clinical and Training Center, University of Tsukuba Hospital, Kasama, Ibaraki, Japan
| | - Keiichi Hagiya
- Department of Anesthesiology and Critical Care Medicine, Ibaraki Prefectural Central Hospital, Kasama, Ibaraki, Japan
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Uchida S, Takekawa D, Kitayama M, Hirota K. Two cases of circulatory collapse due to suspected remimazolam anaphylaxis. JA Clin Rep 2022; 8:18. [PMID: 35249154 PMCID: PMC8898805 DOI: 10.1186/s40981-022-00508-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background Remimazolam was approved in Japan in January 2020. We report two cases of circulatory collapse due to suspected remimazolam anaphylaxis during anesthetic induction. Case presentation Case 1: A 74-year-old male was scheduled for debridement and skin grafting for a severe burn injury. We induced anesthesia with 4 mg of remimazolam and 20 mg of ketamine. The patient subsequently developed treatment-resistant severe hypotension. Case 2: A 59-year-old male was scheduled for laparoscopic-assisted sigmoid colectomy. We induced anesthesia with 9 mg of remimazolam. Within a few minutes, the patient developed treatment-resistant severe hypotension. As serum tryptase was elevated in both cases and only intravenous administration of adrenaline was effective, we considered the circulatory collapse might be due to anaphylaxis. Conclusion We experienced two cases of circulatory collapse due to suspected remimazolam anaphylaxis during anesthetic induction. The prevalence of remimazolam anaphylaxis is not yet known, and further research is needed.
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Affiliation(s)
- Satoshi Uchida
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan.
| | - Daiki Takekawa
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan
| | - Masato Kitayama
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan
| | - Kazuyoshi Hirota
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan
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Murakami Y, Kaneko S, Yokoyama H, Ishizaki H, Sekino M, Murata H, Hara T. Successful treatment of severe adrenaline-resistant anaphylactic shock with glucagon in a patient taking a beta-blocker: a case report. JA Clin Rep 2021; 7:86. [PMID: 34907487 PMCID: PMC8671579 DOI: 10.1186/s40981-021-00490-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/29/2021] [Accepted: 12/04/2021] [Indexed: 01/19/2023] Open
Abstract
Background The efficacy of glucagon for adrenaline-resistant anaphylactic shock in patients taking β-blockers is controversial. However, understanding the efficacy of glucagon is important because adrenaline-resistant anaphylactic shock is fatal. We present a case of severe adrenaline-resistant anaphylactic shock in a patient taking a β-blocker, and glucagon was effective in improving hemodynamics. Case presentation An 88-year-old woman with severe aortic stenosis and taking a selective β-1 blocker underwent transcatheter aortic valve implantation under general anesthesia. Postoperatively, she received 100 mg sugammadex, but 2 min later developed severe hypotension and bronchospasm. Suspecting anaphylactic shock, we intervened by administering adrenaline, fluid loading, and an increased noradrenaline dose. Consequently, the bronchospasm improved, but her blood pressure only increased minimally. Therefore, we administered 1 mg glucagon intravenously, and the hypotension resolved immediately. Conclusions Glucagon may improve hemodynamics in adrenaline-resistant anaphylactic shock patients taking β-blockers; however, its efficacy must be further evaluated in more cases.
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Affiliation(s)
- Yu Murakami
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shohei Kaneko
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Haruka Yokoyama
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hironori Ishizaki
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Motohiro Sekino
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroaki Murata
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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