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Winegarner A, Kendall MC, Stephen M, Siddiqui A. Delayed Anaphylactic Reaction to Midazolam in the Absence of Immediate Respiratory or Skin Manifestations. Case Rep Anesthesiol 2023; 2023:3873076. [PMID: 37767049 PMCID: PMC10522439 DOI: 10.1155/2023/3873076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Anaphylaxis, a type 1 hypersensitivity reaction, is a feared but uncommon complication of medications administered in the perioperative period. The incidence of perioperative hypersensitivity reactions has been reported to range from 1 in 20,000 to 1 in 1,361. Anesthesiologists are well aware of common causes of hypersensitivity such as paralytics and antibiotics; however, less common triggers of anaphylaxis need to be considered as well. Midazolam, a short acting benzodiazepine metabolized by cytochrome P450 enzymes, is considered very safe with a minimal risk profile. Previous reports have described adverse reactions to occur within seconds to minutes following the administration of midazolam. We describe a patient with no known history of asthma or allergies who underwent elective hydrocelectomy with spinal analgesia without incident until 42 minutes later at the conclusion of the procedure, when they experienced circulatory collapse necessitating immediate emergency treatment. This case emphasizes the necessity to improve knowledge and awareness of delayed hypersensitivity reactions following the administration of perioperative medications such as midazolam.
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Affiliation(s)
- Andrew Winegarner
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert School of Medicine at Brown University, Providence 02903, RI, USA
| | - Mark C. Kendall
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert School of Medicine at Brown University, Providence 02903, RI, USA
| | - Mekhala Stephen
- Department of Interventional Pain Management and Anesthesia, Providence Veterans Affairs Medical Center, Providence 02903, RI, USA
| | - Afreen Siddiqui
- Department of Interventional Pain Management and Anesthesia, Providence Veterans Affairs Medical Center, Providence 02903, RI, USA
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Capponi G, Giovannini M, Koniari I, Mori F, Rubino C, Spaziani G, Calabri GB, Favilli S, Novembre E, Indolfi G, De Simone L, Trapani S. Case Report: Perioperative Kounis Syndrome in an Adolescent With Congenital Glaucoma. Front Cardiovasc Med 2021; 8:676188. [PMID: 34568441 PMCID: PMC8461009 DOI: 10.3389/fcvm.2021.676188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/13/2021] [Indexed: 11/13/2022] Open
Abstract
A 12-year-old male patient suffering from congenital glaucoma developed bradycardia, left ventricular failure, and hypotension after induction of anesthesia. Electrocardiography and echocardiography revealed a complete normalization of ECG and a complete spontaneous recovery in the cardiac function 72 hours from the beginning of the clinical manifestations, while cardiac Magnetic Resonance Imaging was performed, and coronary Computed Tomography scan revealed a myocardial bridge of a tract of the left anterior descendent coronary artery. Diagnosis of Kounis syndrome (KS) was made, a relatively novel, under-recognized clinical condition, defined as the manifestation of an acute coronary syndrome accompanied by mast cell activation and platelet aggregation involving interrelated and interacting inflammatory cells in the setting of allergic, hypersensitivity, anaphylactic or anaphylactoid insults. We described one of the first pediatric cases of KS related to anesthetic medications. In children, this syndrome has been only described in isolated case reports or small case series. Thus, it appears critical to report new cases of KS in children to increase the awareness of this disease in pediatric healthcare workers so as to enhance its early recognition and optimal therapeutic strategy. Furthermore, it appears of paramount importance the implementation of universal guidelines accepted by allergology and cardiology societies, in order to standardize the management of pediatric and adult patients with KS. Finally, a close collaboration between pediatric allergists and cardiologists seems fundamental for an optimal multidisciplinary patient care.
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Affiliation(s)
- Guglielmo Capponi
- Cardiology Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Ioanna Koniari
- Electrophysiology and Device Department, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Chiara Rubino
- Department of Pediatrics, Meyer Children's Hospital, Florence, Italy
| | - Gaia Spaziani
- Cardiology Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | | | - Silvia Favilli
- Cardiology Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Giuseppe Indolfi
- Department of Pediatrics, Meyer Children's Hospital, Florence, Italy.,Department of NEUROFARBA, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Luciano De Simone
- Cardiology Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Sandra Trapani
- Department of Pediatrics, Meyer Children's Hospital, Florence, Italy.,Department of Health Sciences, Meyer Children's Hospital, University of Florence, Florence, Italy
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Wang N, Zhang Y, Hu Y, Yang Q, Su Z. Serious bronchospasm induced by cisatracurium besylate: A case report. Medicine (Baltimore) 2021; 100:e25516. [PMID: 33847670 PMCID: PMC8051963 DOI: 10.1097/md.0000000000025516] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/25/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Cis-atracurium as an intermediate-acting non-depolarizing neuromuscular blocker is widely used clinically with less causing cyclic fluctuations and less histamine release. As the use rate increases, allergic reactions and anaphylactoid reactions caused by cis-atracurium increase. PATIENT CONCERNS A 23-year-old woman underwent laparoscopic bariatric surgery. Airway spasm occurred after anesthesia induction and the operation was suspended. After adjustment, the anesthesia was performed with the same anesthetic scheme again. After induction, skin flushing and airway resistance increased, then the symptoms were relieved. When the cis-atracurium was given again, the symptoms of airway spasm reappeared immediately, and after communicating with the family, the operation was successfully completed with rocuronium. DIAGNOSES Serious bronchospasm induced by cisatracurium besylate. INTERVENTIONS The patient was undergone assisted ventilation with continuous positive airway pressure (CPAP) and aminophylline 250 mg, methylprednisolone 80 mg were given intravenously. OUTCOMES There was no any obvious discomfort in the patient's self-report during the next day's visit. The patient was discharged 7 days later. No abnormalities were observed during following 4 weeks. LESSONS Although the anaphylactoid reactions caused by cis-atracurium are rare, the bronchospasm and anaphylactic shock caused by it greatly increase the risk of anesthesia, which should be taken seriously by clinicians. Increased vigilance in diagnosis, and treatment are essential to prevent aggravation and further complication.
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Hypersensitivity reaction to midazolam: a case of cardio-respiratory failure. Postepy Dermatol Alergol 2021; 37:1012-1013. [PMID: 33603624 PMCID: PMC7874856 DOI: 10.5114/ada.2020.102128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/07/2019] [Indexed: 11/17/2022] Open
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Haybarger E, Young AS, Giovannitti JA. Benzodiazepine Allergy With Anesthesia Administration: A Review of Current Literature. Anesth Prog 2017; 63:160-7. [PMID: 27585420 PMCID: PMC5011959 DOI: 10.2344/16-00019.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/06/2016] [Indexed: 12/19/2022] Open
Abstract
The incidence of anaphylactic/anaphylactoid reactions has been reported to vary between 1 : 3500 and 1 : 20,000 cases with a mortality rate ranging from 3 to 9%. Clinical signs present as skin rash, urticaria, angioedema, bronchospasm, tachycardia, bradycardia, and hypotension. Rapid identification and treatment are crucial to overall patient prognosis, as delayed intervention is associated with increased mortality. Diagnosis may be confirmed with clinical presentation, serum tryptase levels, and skin test results. While the main causative agents in anesthetic practice are typically neuromuscular blocking agents (NMBs), latex, and antibiotics, this review aims to discuss recognition, management, and preventive measures in perioperative anaphylactic/anaphylactoid reactions from benzodiazepine administration.
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Affiliation(s)
- Elliot Haybarger
- Dentist Anesthesiologist, Greenville, South Carolina. Former Resident in Dental Anesthesiology, University of Pittsburgh, Pennsylvania
| | - Andrew S. Young
- Resident in Dental Anesthesiology, University of Pittsburgh, Pennsylvania
| | - Joseph A. Giovannitti
- Professor and Chair, Department of Dental Anesthesiology, University of Pittsburgh, Pennsylvania
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Bernardini R, Bonadonna P, Catania P, Passalacqua G. Perioperative midazolam hypersensitivity in a seven-year-old boy. Pediatr Allergy Immunol 2017; 28:400-401. [PMID: 28339137 DOI: 10.1111/pai.12717] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
| | | | - Piera Catania
- Pediatric Unit, San Giuseppe Hospital, Empoli (Florence), Italy
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino-IST-University of Genoa, Genoa, Italy
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Kim KN, Kim DW, Sin YH, Lee SK. Anaphylactic shock caused by intramuscular injection of midazolam during the perioperative period: a case report. Korean J Anesthesiol 2016; 69:510-513. [PMID: 27703633 PMCID: PMC5047988 DOI: 10.4097/kjae.2016.69.5.510] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 02/29/2016] [Accepted: 03/09/2016] [Indexed: 11/29/2022] Open
Abstract
Although anaphylactic shock during the perioperative period is rare, it can be lethal due to severe cardiovascular and respiratory collapse. Midazolam is generally used as premedication for relieving anxiety about the operation, and the danger of anaphylactic shock after intramuscular injection is not widely recognized. We report the first case of anaphylactic shock occurring during the perioperative period after intramuscular injection of midazolam. Since anaphylactic shock after intramuscular injection can be of slow onset, the operation should be delayed if an anaphylactic reaction is suspected, even if the symptoms are limited. In addition, anesthesiologists should be prepared for the occurrence of anaphylaxis at any time in the perioperative period.
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Affiliation(s)
- Kyu Nam Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, Korea
| | - Dong Won Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, Korea
| | - Yeong Hun Sin
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, Korea
| | - Soo Kyung Lee
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, Korea
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Ayuse T, Kurata S, Ayuse T. Anaphylactoid-like Reaction to Midazolam During Oral and Maxillofacial Surgery. Anesth Prog 2015; 62:64-5. [PMID: 26061575 DOI: 10.2344/0003-3006-62.1.64] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
We experienced a case of life-threatening hypotension and bronchoconstriction associated with edema in a patient undergoing resection of a tumor of the right mandible following intravenous midazolam for induction of general anesthesia. We decided to postpone surgery for further examination of a possible drug-induced allergic reaction, and we rescheduled surgery for 1 week later. After administering H1 and H2 histamine antagonists, we administered a slow induction with sevoflurane in nitrous oxide and oxygen plus intravenous atropine sulfate after performing a test dose injection. We safely induced and maintained anesthesia with nitrous oxide, oxygen, and sevoflurane.
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Affiliation(s)
- Terumi Ayuse
- Department of Special Care Dentistry, Nagasaki University Hospital, Nagasaki, Japan
| | - Shinji Kurata
- Department of Dental Anesthesiology, Nagasaki University Hospital, Nagasaki, Japan
| | - Takao Ayuse
- Department of Special Care Dentistry, Nagasaki University Hospital, Nagasaki, Japan
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Abstract
The incidence of anaphylaxis during anesthesia has been reported to range from 1 in 4000 to 1 in 25,000. Anaphylaxis during anesthesia can present as cardiovascular collapse, airway obstruction, and/or skin manifestation. It can be difficult to differentiate between immune and nonimmune mast cell-mediated reactions and pharmacologic effects from the variety of medications administered during general anesthesia. In addition, cutaneous manifestations of anaphylaxis are less likely to be apparent when anaphylaxis occurs in this setting. The evaluation of IgE-mediated reactions to medications used during anesthesia can include skin testing to a variety of anesthetic agents. Specifically, thiopental allergy has been documented by skin tests. Neuromuscular blocking agents such as succinylcholine can cause nonimmunologic histamine release, but there have also been reports of IgE-mediated reactions in some patients. Reactions to opioid analgesics are usually caused by direct mast cell mediator release rather than IgE-dependent mechanisms. Antibiotics that are administered perioperatively can cause immunologic or nonimmunologic reactions. Protamine can cause severe systemic reactions through IgE-mediated or nonimmunologic mechanisms. Blood transfusions can elicit a variety of systemic reactions, some of which might be IgE-mediated or mediated through other immunologic mechanisms. The management of anaphylactic reactions that occur during general anesthesia is similar to the management of anaphylaxis in other situations.
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Affiliation(s)
- Shrikant Mali
- MDS Oral and Maxillofacial Surgery, Sr Lecturer, Department of Oral and Maxillofacial Surgery CSMSS Dental College, Aurangabad, India
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Shin JG, Hwang JH, Lee BS, Park HJ, Lee SH, Lee JN, Han DH, Kim JH. A case of midazolam anaphylaxis. Clin Endosc 2014; 47:262-5. [PMID: 24944992 PMCID: PMC4058546 DOI: 10.5946/ce.2014.47.3.262] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 07/17/2013] [Accepted: 08/15/2013] [Indexed: 11/14/2022] Open
Abstract
Midazolam is a type of anesthetic agent frequently used for conscious sedation during a variety of medical procedures. Anaphylactic reactions to midazolam are rarely reported. However, we observed a case of midazolam hypersensitivity in which emergency measures were required to ensure patient recovery after administration of midazolam as a sedative. The occurrence of the anaphylactic reaction to midazolam was confirmed by elevated serum tryptase levels. The current case report presents a discussion of our findings.
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Affiliation(s)
- Jae Gyu Shin
- Department of Internal Medicine, Busan Medical Center, Busan, Korea
| | - Jong Ho Hwang
- Department of Internal Medicine, Busan Medical Center, Busan, Korea
| | - Ban Seok Lee
- Department of Internal Medicine, Cheju Halla General Hospital, Jeju, Korea
| | - Hye Jung Park
- Department of Internal Medicine, Cheju Halla General Hospital, Jeju, Korea
| | - Sang Ho Lee
- Department of Internal Medicine, Busan Medical Center, Busan, Korea
| | - Jae Nam Lee
- Department of Internal Medicine, Busan Medical Center, Busan, Korea
| | - Dong Hoon Han
- Department of Internal Medicine, Busan Medical Center, Busan, Korea
| | - Ji Ha Kim
- Department of Internal Medicine, Busan Medical Center, Busan, Korea
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11
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An experience with midazolam anaphylactoid reaction. J Anesth 2012; 26:642-3. [PMID: 22467090 DOI: 10.1007/s00540-012-1386-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 03/20/2012] [Indexed: 10/28/2022]
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12
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Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e93-e174. [PMID: 20956032 DOI: 10.1016/j.resuscitation.2010.08.027] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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13
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The use of oral midazolam for perioperative anxiolysis of healthy patients undergoing Mohs surgery: Conclusions from randomized controlled and prospective studies. J Am Acad Dermatol 2011; 64:310-22. [DOI: 10.1016/j.jaad.2010.02.038] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 02/01/2010] [Accepted: 02/23/2010] [Indexed: 11/21/2022]
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14
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Hwang JY, Jeon YT, Na HS, Lee JH, Choi SJ, Jung SH. Midazolam hypersensitivity during the transportation to theater -A case report-. Korean J Anesthesiol 2010; 59 Suppl:S1-2. [PMID: 21286414 PMCID: PMC3030010 DOI: 10.4097/kjae.2010.59.s.s1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Revised: 07/20/2009] [Accepted: 11/25/2009] [Indexed: 11/16/2022] Open
Abstract
This report describes a rare case of perioperative midazolam hypersensitivity in a patient without any history of allergy. A 39-year-old man was admitted for endoscopic pansinus surgery. During transportation to the operating room after injecting antibiotic and midazolam intravenously, the patient complained of shortness of breath. At 3 months after the event, an intradermal sensitivity test for midazolam proved positive indicating the incident was caused by midazolam hypersensitivity.
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Affiliation(s)
- Jin-Young Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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15
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Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP, Adrie C, Alhelail M, Battu P, Behringer W, Berkow L, Bernstein RA, Bhayani SS, Bigham B, Boyd J, Brenner B, Bruder E, Brugger H, Cash IL, Castrén M, Cocchi M, Comadira G, Crewdson K, Czekajlo MS, Davies SR, Dhindsa H, Diercks D, Dine CJ, Dioszeghy C, Donnino M, Dunning J, El Sanadi N, Farley H, Fenici P, Feeser VR, Foster JA, Friberg H, Fries M, Garcia-Vega FJ, Geocadin RG, Georgiou M, Ghuman J, Givens M, Graham C, Greer DM, Halperin HR, Hanson A, Holzer M, Hunt EA, Ishikawa M, Ioannides M, Jeejeebhoy FM, Jennings PA, Kano H, Kern KB, Kette F, Kudenchuk PJ, Kupas D, La Torre G, Larabee TM, Leary M, Litell J, Little CM, Lobel D, Mader TJ, McCarthy JJ, McCrory MC, Menegazzi JJ, Meurer WJ, Middleton PM, Mottram AR, Navarese EP, Nguyen T, Ong M, Padkin A, Ferreira de Paiva E, Passman RS, Pellis T, Picard JJ, Prout R, Pytte M, Reid RD, Rittenberger J, Ross W, Rubertsson S, Rundgren M, Russo SG, Sakamoto T, Sandroni C, Sanna T, Sato T, Sattur S, Scapigliati A, Schilling R, Seppelt I, Severyn FA, Shepherd G, Shih RD, Skrifvars M, Soar J, Tada K, Tararan S, Torbey M, Weinstock J, Wenzel V, Wiese CH, Wu D, Zelop CM, Zideman D, Zimmerman JL. Part 8: Advanced Life Support. Circulation 2010; 122:S345-421. [DOI: 10.1161/circulationaha.110.971051] [Citation(s) in RCA: 250] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lieberman P, Nicklas RA, Oppenheimer J, Kemp SF, Lang DM, Bernstein DI, Bernstein JA, Burks AW, Feldweg AM, Fink JN, Greenberger PA, Golden DBK, James JM, Kemp SF, Ledford DK, Lieberman P, Sheffer AL, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles S, Wallace D. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010; 126:477-80.e1-42. [PMID: 20692689 DOI: 10.1016/j.jaci.2010.06.022] [Citation(s) in RCA: 460] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 04/27/2010] [Accepted: 06/08/2010] [Indexed: 11/19/2022]
Abstract
These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "The Diagnosis and Management of Anaphylaxis Practice Parameter: 2010 Update." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, or the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.
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Affiliation(s)
- Phillip Lieberman
- JointCouncil of Allergy, Asthma&Immunology, 50NBrockway St, #3-3, Palatine, IL 60067, USA.
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Abstract
General anesthesia and anaphylaxis cause profound physiologic changes. When both occur simultaneously, it is often difficult to recognize and identify the medication or product responsible for the latter. Following such an event, the proper assessment, diagnosis, and recommendations are essential to prevent future reactions. This article reviews the more common causes of anaphylaxis during anesthesia.
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Affiliation(s)
- Thomas Chacko
- University of South Florida College of Medicine, 13000 Bruce B. Downs Boulevard, VAR 111D, Tampa, FL 33612, USA
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19
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Abstract
This article focuses on potential complications of standard upper and lower endoscopic procedures. Adverse events associated with endoscopic retrograde cholangiopancreatography, EUS, and certain advanced therapeutic techniques such as mucosal resection are not covered. Rather, the article focuses on the recognition of preprocedure risk factors for various complications and the diagnosis and management for procedure-related adverse events.
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Affiliation(s)
- Lev Ginzburg
- Division of Gastroenterology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
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Abstract
Anesthesiologists use a myriad of drugs during the provision of an anesthetic. Many of these drugs have side effects that are dose related, and some lead to severe immune-mediated adverse reactions. Anaphylaxis is the most severe immune-mediated reaction; it generally occurs on reexposure to a specific antigen and requires the release of proinflammatory mediators. Anaphylactoid reactions occur through a direct non-immunoglobulin E-mediated release of mediators from mast cells or from complement activation. Muscle relaxants and latex account for most cases of anaphylaxis during the perioperative period. Symptoms may include all organ systems and present with bronchospasm and cardiovascular collapse in the most severe cases. Management of anaphylaxis includes discontinuation of the presumptive drug (or latex) and anesthetic, aggressive pulmonary and cardiovascular support, and epinephrine. Although a serum tryptase confirms the diagnosis of an anaphylactic reaction, the offending drug can be identified by skin-prick, intradermal testing, or serologic testing. Prevention of recurrences is critical to avoid mortality and morbidity.
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Affiliation(s)
- David L Hepner
- *Department of Anesthesiology, Perioperative and Pain Medicine, and †Allergy and Clinical Immunology Training Program, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Abstract
Midazolam is a familiar agent commonly used in the emergency department to provide sedation prior to procedures such as laceration repair and reduction of dislocations. Midazolam is also effective in the treatment of generalized seizures, status epilepticus, and behavioral emergencies, particularly when intravenous access is not available. Midazolam is often employed as an induction agent for rapid sequence endotracheal intubation. Midazolam has a rapid onset of action following intravenous, intramuscular, oral, nasal, and rectal administration. Only 50% of an orally administered dose reaches the systemic circulation due to extensive first-pass metabolism. Midazolam is metabolized by the cytochrome P450 enzyme system to several metabolites including an active metabolite, alpha-hydroxymidazolam. Cytochrome P450 inhibitors such as cimetidine can profoundly reduce the metabolism of midazolam. Midazolam has a half-life of approximately 1 h, but this half-life may be prolonged in patients with renal or hepatic dysfunction. Midazolam has been associated with respiratory depression and cardiac arrest when used in combination with an opioid, particularly in the elderly, although all ages are at risk for respiratory depression. Midazolam is relatively free of side effects when used alone and offers several advantages over traditional pharmacological agents such as chloral hydrate and the combination of meperidine, chlorpromazine, and promethazine. Hiccups, cough, nausea, and vomiting are the most commonly reported adverse effects. Many of the adverse effects associated with midazolam can be reversed rapidly by the administration of flumazenil, a competitive benzodiazepine receptor antagonist. Midazolam is a safe and effective agent for providing sedation in the emergency department.
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Affiliation(s)
- S P Nordt
- San Diego Regional Poison Center, University of California, USA
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