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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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Baldo BA. Allergic and other adverse reactions to drugs used in anesthesia and surgery. ANESTHESIOLOGY AND PERIOPERATIVE SCIENCE 2023; 1:16. [PMCID: PMC10264870 DOI: 10.1007/s44254-023-00018-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/02/2023] [Accepted: 04/11/2023] [Indexed: 11/13/2023]
Abstract
The list of drugs patients may be exposed to during the perioperative and postoperative periods is potentially extensive. It includes induction agents, neuromuscular blocking drugs (NMBDs), opioids, antibiotics, sugammadex, colloids, local anesthetics, polypeptides, antifibrinolytic agents, heparin and related anticoagulants, blue dyes, chlorhexidine, and a range of other agents depending on several factors related to individual patients’ clinical condition and progress in the postoperative recovery period. To avoid poor or ultrarapid metabolizers to a particular drug (for example tramadol and codeine) or possible adverse drug reactions (ADRs), some drugs may need to be avoided during or after surgery. This will be the case for patients with a history of anaphylaxis or other adverse events/intolerances to a known drug. Other drugs may be ceased for a period before surgery, e.g., anticoagulants that increase the chance of bleeding; diuretics for patients with acute renal failure; antihypertensives relative to kidney injury after major vascular surgery; and serotonergic drugs that together with some opioids may rarely induce serotonin toxicity. Studies of germline variations shown by genotyping and phenotyping to identify a predisposition of genetic factors to ADRs offer an increasingly important approach to individualize drug therapy. Studies of associations of human leukocyte antigen (HLA) genes with some serious delayed immune-mediated reactions are ongoing and variations of drug-metabolizing cytochrome CYP450 enzymes, P-glycoprotein, and catechol-O -methyltransferase show promise for the assessment of ADRs and non-responses to drugs, particularly opioids and other analgesics. Surveys of ADRs from an increasing number of institutions often cover small numbers of patients, are retrospective in nature, fail to clearly identify culprit drugs, and do not adequately distinguish immune-mediated from non-immune-mediated anaphylactoid reactions. From the many surveys undertaken, the large list of agents identified during and after anesthesia and surgery are examined for their ADR involvement. Drugs are classified into those most often involved, (NMBD and antibiotics); drugs that are becoming more frequently implicated, namely antibiotics (particularly teicoplanin), and blue dyes; those becoming less frequently involved; and drugs more rarely involved in perioperative, and postoperative adverse reactions but still important and necessary to keep in mind for the occasional potential sensitive patient. Clinicians should be aware of the similarities between drug-induced true allergic type I IgE/FcεRI- and pseudoallergic MRGPRX2-mediated ADRs, the clinical features of each, and their distinguishing characteristics. Procedures for identifying MRGPRX2 agonists and diagnosing and distinguishing pseudoallergic from allergic reaction mechanisms are discussed.
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Affiliation(s)
- Brian A. Baldo
- Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney, St Leonards, Australia
- Department of Medicine, University of Sydney, Sydney, NSW Australia
- Lindfield, Australia
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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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Jeon YS, Shim J, Jun EH, Choi ST, Jung HS. Midazolam anaphylaxis during general anesthesia: A case report. Medicine (Baltimore) 2019; 98:e17405. [PMID: 31593093 PMCID: PMC6799541 DOI: 10.1097/md.0000000000017405] [Citation(s) in RCA: 5] [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: 04/25/2019] [Revised: 08/02/2019] [Accepted: 09/10/2019] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Midazolam is known as a safe drug and is widely used as a sedative and an anesthetic adjuvant. Therefore, there is a lack of awareness that midazolam can cause anaphylaxis. Midazolam anaphylaxis is rare, and only a few cases have been reported, but such a risk is always present. In this study, we report a case of midazolam anaphylaxis by an intravenous injection, in the prone position, during general anesthesia. PATIENT CONCERNS A 62-year-old woman was intravenously administered 1 mg midazolam during general anesthesia, and sudden severe hypotension, bronchospasm, decreased oxygen saturation, erythema, and diarrhea occurred. DIAGNOSIS Midazolam anaphylaxis was presumptively diagnosed by clinical symptoms and was confirmed by an intradermal test after 9 weeks. INTERVENTIONS The patient was treated with 100% oxygen, large volume of fluid, epinephrine, phenylephrine, ephedrine, dexamethasone and prednisolone, ranitidine, and flumazenil. OUTCOMES Severe hypotension and decreased oxygen saturation were resolved within 20 minutes of the onset of anaphylaxis, and the patient was discharged after 3 days without any sequelae. LESSONS Midazolam anaphylaxis is very rare, but it can happen always. Therefore, the possibility of anaphylaxis due to midazolam should be considered and always be prepared for treatment.
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Çakmakcı S, Bayhan T, Cihan MK, İlhan İE. Anaphylaxis with midazolam in pediatric hematology-oncology unit: a case report. Turk Arch Pediatr 2018; 53:200-201. [PMID: 30459522 DOI: 10.5152/turkpediatriars.2018.6176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 09/22/2017] [Indexed: 11/22/2022]
Affiliation(s)
- Selma Çakmakcı
- Department of Pediatric Hematology and Oncology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Turan Bayhan
- Department of Pediatric Hematology and Oncology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Meriç Kaymak Cihan
- Department of Pediatric Hematology and Oncology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - İnci Ergürhan İlhan
- Department of Pediatric Hematology and Oncology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
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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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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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