Anaphylactic shock caused by intramuscular injection of midazolam during the perioperative period: a case report

An Unusual Case of Delayed Midazolam Anaphylaxis and a Review of the Current Literature

Midazolam is a commonly used, well-tolerated, anxiolytic, sedative, anesthesia induction agent, and an adjunct for procedural sedation that is used widely in the emergency department. The ability to administer midazolam via multiple routes, including intranasal, makes it a particularly common choice for use in children. Intranasal administration is safe, easy, and well tolerated and has been shown to be an effective method of obtaining anxiolysis and/or sedation. Adverse drug reactions, including allergic reactions, can occur with any medication. However, anaphylaxis is an uncommon phenomenon from midazolam. Despite being one of the most common medications used in the emergency department and operating room, there are only a handful of unequivocal cases of anaphylaxis secondary to midazolam. The rarity of this presentation may lead to delays in care and potential adverse outcomes as a result. We present one such case of a 10-year-old patient who experienced anaphylaxis after administration of intranasal midazolam to facilitate a computed tomography scan.

Delayed Anaphylactic Reaction to Midazolam in the Absence of Immediate Respiratory or Skin Manifestations

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.

A Suspected Anaphylactoid Reaction to Propofol in a Dog

Anaphylactoid reactions to anaesthetic drugs are rarely reported in veterinary medicine. The aim of this report is to describe a suspected anaphylactic reaction to propofol in a 14 years old Shih-Tzu undergoing general anaesthesia for ovariohysterectomy due to a pyometra. The anesthetic protocol included intramuscular methadone for premedication and fentanyl, midazolam and propofol intravenously for co-induction. At endotracheal intubation, the glottis appeared subjectively thickened. Shortly after induction and endotracheal intubation, desaturation, hypercapnia and bradycardia occurred; chest compliance at manual ventilation was poor and peripheral pulses were weak. The procedure was aborted. Pulmonary oedema was diagnosed at thoracic radiography and a cardiogenic origin was excluded via echocardiography. Fluid therapy and glucocorticoids were administered, and mechanical ventilation was started in the intensive care unit. Two hours later, the owner opted for euthanasia due to financial constraints.

Serious bronchospasm induced by cisatracurium besylate: A case report

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.

Midazolam anaphylaxis during general anesthesia: A case report

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.

Recognition and management of dermatologic complications from interventional radiology procedures

A variety of dermatologic complications can occur after interventional radiology procedures, including fluoroscopy-induced radiation dermatitis, thermal skin injury from tumor ablation, non-target embolization to the skin, allergic reactions related to interventional radiology procedures, and dermatitis and infections at catheter sites. Yet, interventional radiologists typically lack training in dermatology. This review focuses on recognition of dermatologic complications and introduces basic principles for management of these complications. By taking a more active role in the diagnosis, management, and follow-up of dermatologic complications, interventional radiologists can improve the care for patients suffering iatrogenic skin inury.