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Gouel-Cheron A, Neukirch C, Kantor E, Malinovsky JM, Tacquard C, Montravers P, Mertes PM, Longrois D. Clinical reasoning in anaphylactic shock: addressing the challenges faced by anaesthesiologists in real time: A clinical review and management algorithms. Eur J Anaesthesiol 2021; 38:1158-1167. [PMID: 33973926 DOI: 10.1097/eja.0000000000001536] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute hypersensitivity reactions to drugs occur infrequently during anaesthesia and the peri-operative period. When clinical presentation includes the classical triad, erythema, cardiovascular abnormalities and increased airway pressure, the diagnosis is evident and the challenge is to prescribe a therapeutic regimen according to guidelines and to manage refractory signs in a timely manner. In many situations, however, the initial clinical signs are isolated, such as increased airway pressure or arterial hypotension. Rendering a differential diagnosis with causes and mechanisms other than acute hypersensitivity reactions (AHRs) is difficult, delaying treatment with possible worsening of the clinical signs, and even death, in previously healthy individuals. In these difficult diagnostic situations, clinical reasoning is mandatory, and guidelines do not explicitly explain the elements on which clinical reasoning can be built. In this article, based on clinical evidence whenever available, experimental data and pathophysiology, we propose algorithms that have been evaluated by experts. The goal of these algorithms is to provide explicit elements on which the differential diagnosis of AHRs can be made, accelerating the implementation of adequate therapy.
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Affiliation(s)
- Aurelie Gouel-Cheron
- From the Anaesthesiology and Critical Care Medicine Department, DMU PARABOL, Bichat Hospital, AP-HP (AGC, EK, PM, DL), Antibody in Therapy and Pathology, Pasteur Institute, UMR 1222 INSERM, Paris, France (AGC), Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA (AGC), Pulmonology Department, Bichat Hospital, AP-HP, Paris University (CN), INSERM UMR 1152, Paris University, DHU FIRE, Paris (CN, PM), Anaesthesiology and Critical Care Medicine Department, Maison Blanche Hospital, Centre Hospitalier Universitaire de Reims, Reims (JM-M), Anaesthesiology and Critical Care Medicine Department, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg (CT, PM-M), Paris University (PM, DL), EA 3072, Institut de Physiologie, FMTS, Faculté de Médecine de Strasbourg, Université de Strasbourg, Strasbourg (PM-M) and INSERM1148, Paris, France (DL)
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Tajima K, Zheng F, Collange O, Barthel G, Thornton SN, Longrois D, Levy B, Audibert G, Malinovsky JM, Mertes PM. Time to Achieve Target Mean Arterial Pressure during Resuscitation from Experimental Anaphylactic Shock in an Animal Model. A Comparison of Adrenaline Alone or in Combination with Different Volume Expanders. Anaesth Intensive Care 2019; 41:765-73. [DOI: 10.1177/0310057x1304100612] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- K. Tajima
- Faculty of Medicine, Groupe choc, U1116 Inserm, University of Lorraine, Vandoeuvre-lès-Nancy, France
- Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - F. Zheng
- Faculty of Medicine, Groupe choc, U1116 Inserm, University of Lorraine, Vandoeuvre-lès-Nancy, France
- Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - O. Collange
- Faculty of Medicine, Groupe choc, U1116 Inserm, University of Lorraine, Vandoeuvre-lès-Nancy, France
- éanimations Chirurgicales, SAMU, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - G. Barthel
- Faculty of Medicine, Groupe choc, U1116 Inserm, University of Lorraine, Vandoeuvre-lès-Nancy, France
- Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - S. N. Thornton
- Faculty of Medicine, Groupe choc, U1116 Inserm, University of Lorraine, Vandoeuvre-lès-Nancy, France
- Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - D. Longrois
- Faculty of Medicine, Groupe choc, U1116 Inserm, University of Lorraine, Vandoeuvre-lès-Nancy, France
- Département d'Anesthésie-Réanimation Chirurgicale, Hôpital Bichat-Claude Bernard, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - B. Levy
- Faculty of Medicine, Groupe choc, U1116 Inserm, University of Lorraine, Vandoeuvre-lès-Nancy, France
- Service de Réanimation Médicale, Institut Lorrain du Coeur et des Vaisseaux, Vandoeuvre-lès-Nancy, France
| | - G. Audibert
- Faculty of Medicine, Groupe choc, U1116 Inserm, University of Lorraine, Vandoeuvre-lès-Nancy, France
- Département d'Anesthésie-Réanimation Chirurgicale, Centre Hospitalier Universitaire (CHU) Central, Nancy, France
| | - J. M. Malinovsky
- Faculty of Medicine, Groupe choc, U1116 Inserm, University of Lorraine, Vandoeuvre-lès-Nancy, France
- Département d'Anesthésie-Réanimation Chirurgicale, CHU de Reims, Reims, France
| | - P. M. Mertes
- Faculty of Medicine, Groupe choc, U1116 Inserm, University of Lorraine, Vandoeuvre-lès-Nancy, France
- Pôle Anesthésie, Réanimations Chirurgicales, SAMU, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Jeong WJ, Kim WY, Son JH, Lee YS, Kim JH, Park YC. Anaphylaxis with angioedema by rocuronium during induction of general anesthesia -A case report-. Korean J Anesthesiol 2010; 58:391-5. [PMID: 20508798 PMCID: PMC2876862 DOI: 10.4097/kjae.2010.58.4.391] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 07/06/2009] [Accepted: 07/07/2009] [Indexed: 11/10/2022] Open
Abstract
Perioperative anaphylaxis is characterized by severe respiratory and cardiovascular manifestations. Correct management of anaphylaxis during anaesthesia requires a multidisciplinary approach with prompt recognition and treatment of the acute event by the attending anesthesiologist. A 34-year-old woman was scheduled to undergo endo venous laser therapy of varicose veins. She had no history of allergies and had never undergone general anesthesia. General anesthesia was induced with propofol and rocuronium bromide. Approximately three minutes after rocuronium administration, hypotension and tachycardia developed and angioedema around the eyelids and skin rashes and urticaria appeared. The patient received ephedrine and hydrocortisone with hydration. After achieving stable vital signs and symptom relief, surgery was performed without complications. A postoperative skin dermal test performed to identify the agent responsible revealed a positive skin test for rocuronium.
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Affiliation(s)
- Won Ju Jeong
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Ansan Hospital, Ansan, Korea
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