Ceftriaxone-induced Kounis syndrome: A case report and review of the literature

Kounis syndrome is defined as cardiovascular symptoms that occur secondary to allergic or hypersensitivity insults, and is also called allergic angina and allergic myocardial infarction. We report a case of pre-operative ceftriaxone-induced Kounis syndrome with no evident dermatological manifestation, and describe our diagnostic dilemma. The patient was symptomatically managed and discharged in stable condition with a warning against future use of ceftriaxone.

[Anafilaxia perioperatoria a sevoflurano, un caso muy raro]

Background

Perioperative anaphylaxis can be life-threatening. The global incidence is estimated to be 1 in 10,000-20,000 procedures. The most common agents are neuromuscular blockers, latex, and antibiotics. There are very few reports of allergies to inhaled anesthetics such as sevoflurane, which is considered relatively safe in patients with drug allergies.

Case report

12-year-old patient, admitted to oncology, diagnosed with acute lymphoblastic leukemia. History of two perioperative hypersensitivity reactions. In the first event, lidocaine and rupivacaine were administered, he presented urticaria, managed with an antihistamine. On the second occasion, he received only sevoflurane and presented anaphylaxis, treated with intramuscular adrenaline. Later during intrathecal therapy, he received sevoflurane, he presented rash and arterial hypotension, managed again with adrenaline, with total remission of symptoms. Retrospectively Brighton criteria level I of certainty, classified as serious by Brown. Hypersensitivity to sevoflurane was suspected, ruling out other anesthetics such as lidocaine and rupivacaine with negative intradermal skin tests. Molecular components for latex were requested with negative results for Hev b 1, Hev b 3, Hev b 6. Due to the above and associated with the characteristics of the drug, a basophil activation test for sevoflurane was performed with an activation percentage of 50% (positive). Perioperative anaphylaxis due to sevoflurane is confirmed.

Conclusion

All drugs involved in perioperative hypersensitivity reactions should be considered to establish adequate and safe treatment alternatives for this small group of patients.

Severe perioperative anaphylaxis: Incidence in a tertiary hospital in Spain over a 20-year period. A historical cohort study

OBJECTIVE

To assess the incidence of severe perioperative anaphylaxis, the mechanisms involved, the value of laboratory/skin tests, and the most effective treatments.

METHODS

A historical cohort study conducted in a tertiary public hospital in Spain. Patients that had undergone anaesthesia during the 20-year period were included. In these patients, 66 cases of severe anaphylaxis were found. In patients with suspicion of severe anaphylaxis, levels of blood histamine at less than 15min and serum tryptase at 2, 6, and 24h following the reaction were determined. Skin and specific IgE tests were performed between 4 and 8 weeks later.

RESULTS

Over the 20-year period, 288 594 anaesthetic procedures were performed. We observed cases of 66 severe anaphylaxis reaction (59% men; age, 60.8±17.3 years. Symptoms observed were cardiovascular (86%), respiratory (73%), and mucocutaneous (56%). Elevated serum tryptase levels were associated with degree of severity at 2 (P<.0001) and 6h (P=.026) and were highest in IgE-mediated reactions (P=.020). All patients required treatment, and 3 events were fatal. In 84.8% of patients, skin and/or specific IgE tests were positive for antibiotics (35.8%), non-steroidal anti-inflammatory drugs (23.1%), neuromuscular blocking agents (15.4%) and latex (15.4%).

CONCLUSIONS

The incidence of severe anaphylaxis in our hospital was 1 in 4.373 anaesthetic procedures, with a death rate of 4.5%. All cases required treatment. Serum tryptase was a good predictor of reaction severity. The most frequent causative agents were antibiotics, non-steroidal anti-inflammatory drugs, neuromuscular blocking agents and latex.

Nursing care for patients with Kounis syndrome

Kounis syndrome (KS) is defined as the occurrence of a coronary event secondary to a severe allergic reaction. This syndrome is described as poorly known, underdiagnosed and with a low prevalence whose aetiology is difficult to know due to the large number of causative agents. The objective is to create an individualized care plan for a patient with Kounis syndrome. The nursing assessment was performed on admission using Virginia Henderson's need theory. A care plan was developed following the NANDA-NOC-NIC taxonomy. After the planning and execution phase, the proposed activities were evaluated, thus verifying that the objectives had been achieved.

Mixed shock in patients with acute myocardial infarction: Nursing interventions

INTRODUCTION AND OBJECTIVES

We present a clinical case of a 40-year-old woman diagnosed with acute myocardial infarction (AMI) in Killip I who was admitted to our hospital. She experienced complications in the haemodynamic lab and in the operating room, including cardiogenic and anaphylactic shock requiring ventricular assist support. Conservative management support with inotropes and vasopressors in cardiogenic shock has been shown to be insufficient in many patients to maintain adequate perfusion and prevent irreversible multiple organ dysfunction syndrome. For this reason, short-term mechanical circulatory support systems are increasing substantially. The objective of this article is to develop optimal and individualised care plans using the NANDA, NOC, NIC taxonomies.

CLINICAL OBSERVATION

An evaluation based on Virginia Henderson's basic needs was made, and two altered needs stood out: breathing and circulation. The patient required mechanical ventilation and mechanical circulatory support.

INTERVENTIONS

In relation to the highlighted needs, six diagnoses were prioritized according to the NANDA taxonomy using the Análisis de Resultado del Estado Actual (AREA) (Outcome-Present State Test (OPT)) model: risk of decreased cardiac output, impaired spontaneous ventilation, impaired tissue integrity, risk of disuse syndrome, risk of infection and risk of hypothermia.

DISCUSSION AND CONCLUSIONS

Outcome criteria scores showed a favourable evolution after 96 h. The development of a standardized NANDA-NOC-NIC language allowed us to organize the nursing care plan.

Alpha-gal syndrome. Allergy to red meat and gelatin

INTRODUCTION

Alpha-gal syndrome is a potentially severe food allergy caused by the presence of alpha-gal-specific IgE. The aim of this study is to describe our series of 13 patients.

MATERIAL AND METHODS

This work is a retrospective study of patients diagnosed in 2016 and 2017. Skin tests were performed with commercial extract and gelaspan as well as specific IgE determination for alpha-gal and different types of meat.

RESULTS

Thirteen patients diagnosed with alpha-gal syndrome were analyzed; 9 of them had anaphylaxis, 6 of whom had been diagnosed with idiopathic anaphylaxis. All had a positive skin test with gelaspan, though this was not true with the commercial extracts, whose results were less conclusive.

CONCLUSIONS

We believe that a diagnosis of idiopathic anaphylaxis may prevent the identification of patients with alpha-gal syndrome. The gelaspan skin test is more useful than commercial extracts.

Mixed shock in patients with acute myocardial infarction: Nursing interventions

INTRODUCTION AND OBJECTIVES

We present a clinical case of a 40-year-old woman diagnosed with acute myocardial infarction (AMI) in Killip I who was admitted to our hospital. She experienced complications in the haemodynamic lab and in the operating room, including cardiogenic and anaphylactic shock requiring ventricular assist support. Conservative management support with inotropes and vasopressors in cardiogenic shock has been shown to be insufficient in many patients to maintain adequate perfusion and prevent irreversible multiple organ dysfunction syndrome. For this reason, short-term mechanical circulatory support systems are increasing substantially. The objective of this article is to develop optimal and individualised care plans using the NANDA, NOC, NIC taxonomies.

CLINICAL OBSERVATION

An evaluation based on Virginia Hendersońs basic needs was made, and two altered needs stood out: breathing and circulation. The patient required mechanical ventilation and mechanical circulatory support.

INTERVENTIONS

In relation to the highlighted needs, six diagnoses were prioritized according to the NANDA taxonomy using the Análisis de Resultado del Estado Actual (AREA) (Outcome-Present State Test (OPT)) model: risk of decreased cardiac output, impaired spontaneous ventilation, impaired tissue integrity, risk of disuse syndrome, risk of infection and risk of hypothermia.

DISCUSSION AND CONCLUSIONS

Outcome criteria scores showed a favourable evolution after 96h. The development of a standardized NANDA-NOC-NIC language allowed us to organize the nursing care plan.

Managing urticaria in the emergency department: recommendations of a multidisciplinary expert panel

Urticaria and angioedema account for many visits to emergency departments. It is important to diagnose and treat them properly at this level of care and to suggest treatments and guidance that can make additional visits unnecessary. A panel of experts in dermatology and emergency medicine reviewed the main guidelines and publications on urticaria and angioedema. The panel then developed and reached consensus on practical approaches and tools for managing urticaria, angioedema, and anaphylaxis in the emergency department. The resulting statement is a guide to management, with algorithms for differential diagnosis and treatment and recommendations for patient referral. Implementing these guidelines, which are supported by the Spanish Academy of Dermatology and Venereology (AEDV) and the Spanish Society of Emergency Medicine (SEMES) will facilitate optimal management of emergency department patients with urticaria and angioedema as well as improve interdepartmental relations.

Safety in dermatologic procedures: anaphylaxis, vasovagal reaction, and hyperventilation

This article, part of a the series on safety in dermatologic procedures, covers the diagnosis, prevention, management, and treatment of 3 situations or conditions. The first condition we address is anaphylaxis, an uncommon but severe and potentially fatal reaction that must be recognized quickly so that urgent management coordinated with an anesthesiologist can commence. The second is fainting due to a vasovagal reaction, which is the most common complication in dermatologic surgery. This event, which occurs in 1 out of every 160 procedures, usually follows a benign course and resolves on its own. However, in patients susceptible to vasovagal reactions, syncope may lead to asystole and cardiac arrest. The third is acute hyperventilation syndrome, which is an anomalous anxiety-related increase in breathing rate beyond metabolic requirements. Brief practical recommendations for managing all 3 events are included.

Safety in Dermatologic Procedures: Anaphylaxis, Vasovagal Reaction, and Hyperventilation

This article, part of a the series on safety in dermatologic procedures, covers the diagnosis, prevention, management, and treatment of 3 situations or conditions. The first condition we address is anaphylaxis, an uncommon but severe and potentially fatal reaction that must be recognized quickly so that urgent management coordinated with an anesthesiologist can commence. The second is the vasovagal reaction, which is the most common complication in dermatologic surgery. This event, which occurs in 1 out of every 160 procedures, usually follows a benign course and resolves on its own. However, in patients susceptible to vasovagal reactions, syncope may lead to asystole and cardiac arrest. The third is acute hyperventilation syndrome, which is an anomalous anxiety-related increase in breathing rate beyond metabolic requirements. Brief practical recommendations for managing all 3 events are included.

Amoxicillin-clavulanic acid-induced type II Kounis syndrome during general anaesthesia complicated with hypoxic-ischaemic encephalopathy

Anaphylaxis is a severe acute multisystem syndrome involving massive mediator release from mast cells and basophils. Although the entire arterial system can be affected, when coronary arteries are the main targets, Kounis syndrome needs to be considered. Cerebral artery involvement has also been suggested in rarer MC-mediator release episodes; so-called 'Kounis-like' syndrome. Cerebral ischaemic lesions can then result from low blood pressure or direct proinflammatory and/or vasoconstrictive mediator action in the cerebral arterial system. Diagnosis can be difficult in anaesthetised patients, as low blood pressure can have multiple causes. Treatment is also challenging, as administering adrenaline can worsen ischaemia. We report the first case of amoxicillin-clavulanic acid-induced type II Kounis syndrome under general anaesthesia, complicated with severe, irreversible and subsequently fatal encephalopathy of ischaemic origin. This case can contribute to awareness of less common Kounis syndrome manifestations, including severe cerebral involvement, or other anaphylactic reactions with atypical presentations.

[Patent blue V dye anaphylaxis: a case report and literature review]

BACKGROUND

Anaphylaxis is a constant perioperative concern due to the exposure to several agents capable of inducing hypersensitivity reactions. Patent blue V (PBV), also known as Sulfan Blue, a synthetic dye used in sentinel node research in breast surgery, is responsible for 0.6% of reported anaphylactic conditions. We present a case of a 49-year-old female patient who underwent left breast tumorectomy with sentinel lymph node staging using PBV and experienced an anaphylactic reaction.

METHODS

We conducted a literature search through PubMed for case reports, case series, reviews, and systematic reviews since 2005 with the keywords "anaphylaxis" and "patent blue". We then included articles found in these publications' reference sections.

RESULTS

We found 12 relevant publications regarding this topic. The main findings are summarized, with information regarding the clinical presentation, management, and investigation protocol. Hypotension is the most common clinical manifestation. The presentation is usually delayed when compared with anaphylaxis from other agents, and cutaneous manifestations are occasionally absent. Patients may have had previous exposure to the dye, used also as a food, clothes and drug colorant.

CONCLUSION

The diagnosis of anaphylaxis in patients under sedation or general anesthesia may be difficult due to particularities of the perioperative context. According to the published literature, the presentation of the reaction is similar in most cases and a heightened clinical sense is key to address the situation appropriately. Finding the agent responsible for the allergic reaction is of paramount importance to prevent future episodes.

[Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis]

This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.

[Update on perioperative hypersensitivity reactions: joint document of the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part I: post-crisis guidelines and treatment]

Experts from the Brazilian Association of Allergy and Immunology (ASBAI) and the Brazilian Society of Anesthesiology (SBA) interested in the issue of perioperative anaphylaxis, and aiming to strengthen the collaboration between the two societies, combined efforts to study the topic and to prepare a joint document to guide specialists in both areas. The purpose of the present series of two articles was to report the most recent evidence based on the collaborative assessment between both societies. This first article will consider the updated definitions, treatment and guidelines after a perioperative crisis. The following article will discuss the major etiologic agents, how to proceed with the investigation, and the appropriate tests.

Anaphylactic risk due to systemic mastocytosis: Perioperative management in cardiac surgery

Mastocytosis is a disease characterised by an abnormal proliferation of mast cells. The degranulation of mast cells can be triggered by chemical, physical, and psychological factors, and in severe cases may be accompanied by cardiovascular alterations and shock. Tryptase concentrations greater than 20ug/L may be associated with an increased risk of mastocyte degranulation. The case is presented on a 71 year-old man that underwent an aortic valve replacement and aortic-coronary bypass surgery. He had an indolent systemic mastocytosis and a history of histaminergic crises, with a baseline value of tryptase prior to surgery of 58.1ug/L.

Anaphylactic shock versus Kounis syndrome in cardiac surgery: Differential diagnosis

Although Kounis syndrome was described almost 3 decades ago, there has been a notable increase in the reports of cases of acute coronary syndromes developed in the context of allergic reactions, also known as Kounis syndrome. This article discusses the diagnostic possibility in the face of an acute biventricular failure in the course of an anaphylactic reaction during the intra-operative period of a cardiac valve surgery.

Kounys syndrome after rocuronium administration

Kounis syndrome encompasses concepts including angina and allergic infarction described in relation to exposure to different allergens. The aim of this article is to describe a case of Kounis Syndrome type II after exposure to rocuronium as well as the patholophysiology and the treatment of this syndrome.

[Perianesthetic refractory anaphylactic shock with cefuroxime in a patient with history of penicillin allergy on multiple antihypertensive medications]

We report a case of perianesthetic refractory anaphylactic shock with cefuroxime in a patient with history of penicillin allergy on regular therapy with atenolol, losartan, prazosin and nicardipine. Severe anaphylactic shock was only transiently responsive to 10mL of (1:10000) epinephrine and needed norepinephrine and dopamine infusion. Supportive therapy with vasopressors and inotropes along with mechanical ventilation for the next 24hours resulted in complete recovery. She was successfully operated upon 2 weeks later with the same anesthetic drugs but intravenous ciprofloxacin as the alternative antibiotic for perioperative prophylaxis.

A case report: Nursing interventions on a patient with anaphylactic shock in ICU

INTRODUCTION AND OBJECTIVES

The care plan of a 42-year-old woman with anaphylactic shock, secondary to ingestion of amoxicillin/clavulanic acid, with upper airway involvement due to laryngeal angioedema, is presented. Previously she had had two episodes of angioedema of unknown origin. The incidence of this phenomenon is between 3.2 and 10 cases/100,000 people/year.

CLINICAL OBSERVATION

An evaluation was made and three altered necessities stood out: breathing and circulation (she needed mechanical ventilation and noradrenalin perfusion), elimination (she required furosemide to keep an acceptable diuresis time), and hygiene and skin protection (she presented generalised hyperaemia, lip, lingual and oropharyngeal oedema). The hospital's Clinical Research Ethics Committee requested the patient's informed consent to access her clinical history.

INTERVENTIONS

According to the altered necessities, seven diagnoses were prioritised according to NANDA taxonomy: risk of allergic response, risk of infection, risk of ineffective renal perfusion, decreased cardiac output, impaired spontaneous ventilation, risk of unstable blood glucose level, and risk of dysfunctional gastrointestinal motility.

DISCUSSION AND CONCLUSIONS

Scores of outcome criteria showed a favourable evolution after 24hours. The development of a standardised NANDA-NOC-NIC language in the clinical case presented allowed us to organise the nursing work, facilitating recording and normalising clinical practice. As a limitation of this case, we didn't have serial plasma levels of histamine and tryptase to assess the evolution of anaphylactic symptoms. Highlight the importance of health education in a patient with a history of angioedema.

Allergic reaction to patent blue dye in breast surgery - case report

We present a case of allergic reaction to patent blue in a patient who underwent excision of sentinel lymph node associated with segmental breast resection. About 20min after the dye injection, the patient developed hypotension (BP=70×30mmHg) associated with increased heart frequency. The patient was treated successfully with decreased inspired fraction of inhaled anesthetic and fluid replacement. At the end of the procedure, she presented with bluish urticarial-like plaques on the head, neck, upper limbs, and trunk; hydrocortisone was then used. The patient recovered uneventfully and was discharged from the PACU 2h after the end of surgery without skin changes, and was discharged from hospital on the morning after surgery. The incidence of allergic reactions with the use of patent blue is far superior to the hypersensitivity reactions seen with anesthetic and adjuvant drugs. Therefore, the anesthesiologist must be aware of cardiovascular instability associated with skin changes during the use of patent blue, for early diagnosis and appropriate treatment of this hypersensitivity reaction to this dye.

Perioperative anaphylaxis

BACKGROUND AND OBJECTIVE

Anaphylaxis remains one of the potential causes of perioperative death, being generally unanticipated and quickly progress to a life threatening situation. A narrative review of perioperative anaphylaxis is performed.

CONTENT

The diagnostic tests are primarily to avoid further major events. The mainstays of treatment are adrenaline and intravenous fluids.

CONCLUSION

The anesthesiologist should be familiar with the proper diagnosis, management and monitoring of perioperative anaphylaxis.

[Perioperative anaphylaxis]

BACKGROUND AND OBJECTIVE

Anaphylaxis remains one of the potential causes of perioperative death, being generally unanticipated and quickly progressing to a life-threatening situation. A review of perioperative anaphylaxis is performed.

CONTENT

The diagnostic tests are important mainly to avoid further major events. The mainstays of treatment are adrenaline and intravenous fluids.

CONCLUSION

The anesthesiologist should be familiar with the proper diagnosis, management and monitoring of perioperative anaphylaxis.

[Consensus position document on the child with an allergic reaction after vaccination or an allergy to vaccine components]

Vaccinations are one of the main public health tools for the control of vaccine-preventable diseases. If a child is labeled to have had an allergic reaction to a vaccine, the next immunizations will probably be suspended in that child, with the risks involved in this decision. The rate of severe allergic reactions is very low, ranging between 0.5-1/100,000 doses. The causes of allergic reactions to vaccines, more than the vaccine itself, are often due to residual protein components in the manufacturing process, such as gelatin or egg, and rarely to yeast or latex. Most of vaccine reactions are mild, localized at the site of injection, but in some circumstances, severe anaphylactic reactions can occur. If an immediate-type allergic reaction is suspected when vaccinating, or a child allergic to some of the vaccine components has to be vaccinated, a correct diagnosis of the possible allergy has to be made. The usual components of each vaccine should be known, in order to determine if vaccination can be performed safely on the child.

[Allergic reaction to patent blue dye in breast surgery - case report]

We present a case of allergic reaction to patent blue in a patient who underwent excision of sentinel lymph node associated with segmental breast resection. About 20minutes after the dye injection, the patient developed hypotension (BP=70×30mmHg) associated with increased heart frequency. The patient was treated successfully with decreased inspired fraction of inhaled anesthetic and fluid replacement. At the end of the procedure, she presented with bluish urticarial - like plaques on the head, neck, upper limbs, and trunk; hydrocortisone was then used. The patient recovered uneventfully and was discharged from the PACU two hours after the end of surgery without skin changes, and was discharged from hospital on the morning after surgery. The incidence of allergic reactions with the use of patent blue is far superior to the hypersensitivity reactions seen with anesthetic and adjuvant drugs. Therefore, the anesthesiologist must be aware of cardiovascular instability associated with skin changes during the use of patent blue, for early diagnosis and appropriate treatment of this hypersensitivity reaction to this dye.

Perianesthetic refractory anaphylactic shock with cefuroxime in a patient with history of penicillin allergy on multiple antihypertensive medications

We report a case of perianesthetic refractory anaphylactic shock with cefuroxime in a patient with history of penicillin allergy on regular therapy with atenolol, losartan, prazosin and nicardipine. Severe anaphylactic shock was only transiently responsive to 10mL of (1:10,000) epinephrine and needed norepinephrine and dopamine infusion. Supportive therapy with vasopressors and inotropes along with mechanical ventilation for the next 24hours resulted in complete recovery. She was successfully operated upon 2 weeks later with the same anesthetic drugs but intravenous ciprofloxacin as the alternative antibiotic for perioperative prophylaxis.

[Importance of selective immunoglobulin A deficiency]

Selective IgA deficiency is the most common primary immunodeficiency. Little is known about the pathogenetic mechanisms leading to this disease. It is estimated that the incidence of this disease in Spain is 1:163. We report 3 cases diagnosed in Primary Care. Most people with selective IgA deficiency are usually asymptomatic and are diagnosed by chance, but patients with recurrent respiratory infections; gastrointestinal, allergic and autoimmune diseases can be associated with this disease. Although there is no treatment at present, its importance lies in the association with different diseases, such as coeliac disease or idiopathic thrombocytopenic purpura. Another important feature is the risk of anaphylaxis after transfusion, and the possible progression to Common Variable Immunodeficiency. It is important to know the vaccines that we can use due to the risk of disease.