Intraop Anaphylaxis Management

[Shimmy8]

Had a case recently that I'd like to throw out there.

I'm going post the full case at a later date when I get all my thoughts together, but for those of you who have treated true (or suspected) anaphylactic reactions in the OR, how quickly did patient bounce back with usual treatments? Epi, benadryl, pepcid, steroids, etc.

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[ranvier]

Correct diagnosis is everything. That list of therapy implies very different acuities. I hope it ended well and you gave epinephrine early even in small doses as first. I've had two with roc lifetime with immediate response and no apparant long term sequelae. So far none with bridion.

Remember this is a public forum.

 

[MirrorTodd]

The one I've seen responded well to epi. Pt was already intubated, cause was intraop antibiotics. I'm not even sure if you could call it anaphylaxis cause we caught it so early, it never really progressed.

 

[deleted171991]

I haven't encountered an episode yet, but epi is the main treatment. Everything else is secondary, once the patient is stabilizing. The key with epi in anaphylaxis is not to overdose it (stroke, MI), and not to underdose it either, hence titration is important. You should be able to see an effect in a few minutes, unless you're underdosing it.

The correct treatment for every other doctor should be 0.3-0.5 mg IM (I've seen MI from IV epi in anaphylaxis). Since we are anesthesiologists, we can titrate epi IV to effect, up to 50-100 mcg IV at a time (starting with even less, if possible, as the first trial dose).

 

[anbuitachi]

responded well to Epi, but epi is short lasting, so had to start epi infusion to keep it under control

 

[IkeBoy18]

Had a 8wk old? pedi pt with recently repaired TEF in the OR for DL, already had marginal SpO2 (~low 90s) at baseline , but started to desat to the mid/low 80s suddenly during timeout. Increased PEEP, listened to lungs, b/l breath sounds, tube in place.. coincidentally, no wheezes. Started bagging pt and playing around with vent settings, as I was listening to lungs a 2nd time, noticed rash on whole body that previously wasnt there. Gave 3mcgs of epi and patient bounced back immediately.

Peak pressures only subtlely increased, no wheezes, no hypotension, just bronchospasm and desaturations. The only new med is one we gave 10min prior to timeout, cefepime.

 

[drmwvr]

Does protamine reaction count? "Full court press" as they say...but what made the turn around was the epinephrine. Less would have been better, but about a mg was given. Seconds seem a lot longer in these situations. Wondering how much blood is moving affects how much to give and when. Very difficult to "wait and see" after a dose of 100 mcgs of epi...takes a lot of discipline and experience.

 

[Ronin786]

Had one from the chloraprep while doing a line for a cardiac case. Was pretty bad, needed a night in the unit on a low dose epi infusion. Thankfully wasn't showing up for bypass, that could have been even more hairy.

I recall seeing data that some anesthesiologists are hesitant to give epi even with full-blown anaphylaxis given the tachycardia that's usually already present. It's the mainstay treatment though and needs to be done.

 

[Shimmy8]

The full case will be posted sometime in the private forum.

I saw one case in residency where I came in when they overhead stat paged anesthesia and I helped line up, draw labs, etc. but I wasn't the primary.

Interesting to see the variety above as some resolved quickly, some requiring epi infusions, etc.

 

[deleted59964]

This is a nice resource

http://www.anzaag.com/Mgmt Resources.aspx

 

[fakin' the funk]

Had a case recently that I'd like to throw out there.

I'm going post the full case at a later date when I get all my thoughts together, but for those of you who have treated true (or suspected) anaphylactic reactions in the OR, how quickly did patient bounce back with usual treatments? Epi, benadryl, pepcid, steroids, etc.

I've been involved in 3 legit anaphylaxes during my short career. Two were to rocuronium, the other to isosulfan blue (lymphazurin). All 3 were post-induction, pre-incision. Tachycardia was the first sign in all 3.

Epi in small doses is your mainstay, assuming you make the correct diagnosis in a timely fashion. 10-50mcg is likely all that is needed at first. If you get behind, you might need 100+mcg (or compressions). Bolus only lasts a few minutes obviously so then you are reassessing the need every few minutes. In my n = 3, they all needed an epi drip and postprocedure ICU (cases cancelled obviously). In a pinch you might throw in a unit or two of vasopressin. The antihistamines and steroids are kind of window dressing. Be aggressive with volume. Don't forget to draw your tryptase -- though it might be negative anyway.

There is a good review in a EM journal somewhere out there. Important to note that it's a very variable condition. Usually when we see it, it's from a IV injected medication, so severity is likely to be high (as opposed to, say, shellfish allergy with a more localized effect).

 

[nimbus]

I've been involved in 3 legit anaphylaxes during my short career. Two were to rocuronium, the other to isosulfan blue (lymphazurin). All 3 were post-induction, pre-incision. Tachycardia was the first sign in all 3.

If the reactions occurred shortly after induction, how do you know which medication caused it? Were the patients tested afterward?

 

[IlDestriero]

responded well to Epi, but epi is short lasting, so had to start epi infusion to keep it under control

That's the problem with IV epi. It doesn't last long enough, the patient can quickly get worse again, and you need to start an EPI infusion. If I'm knee deep in the stool in the middle of the night and don't know how long an epi drip is going to take the pharmacy to make, I'm going with IV bolus and then an IM shot from the auto injector. We have them in the code carts, peds and adult sizes. If the patient is stabilizing and there's time, then I'd just make my own. If the patient is arresting, just give the IM and be done with it, after a nice epi kiss IV of course. Then you're free to deal with the disaster better while the IM bolus continues to work to stabilize the anaphylactic reaction. You can't trust a nurse or someone else to try to make you an infusion while you're running a code on the patient.
Hope it all worked out OK and you didn't get too many gray hairs.


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Il Destriero

 

[anbuitachi]

That's the problem with IV epi. It doesn't last long enough, the patient can quickly get worse again, and you need to start an EPI infusion. If I'm knee deep in the stool in the middle of the night and don't know how long an epi drip is going to take the pharmacy to make, I'm going with IV bolus and then an IM shot from the auto injector. We have them in the code carts, peds and adult sizes. If the patient is stabilizing and there's time, then I'd just make my own. If the patient is arresting, just give the IM and be done with it, after a nice epi kiss IV of course. Then you're free to deal with the disaster better while the IM bolus continues to work to stabilize the anaphylactic reaction. You can't trust a nurse or someone else to try to make you an infusion while you're running a code on the patient.
Hope it all worked out OK and you didn't get too many gray hairs.


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Il Destriero

what? i just make my own epi bag and hang it. it takes barely any time. we have plenty of epi vials in our carts

 

[pgg]

Does protamine reaction count? "Full court press" as they say...but what made the turn around was the epinephrine. Less would have been better, but about a mg was given. Seconds seem a lot longer in these situations. Wondering how much blood is moving affects how much to give and when. Very difficult to "wait and see" after a dose of 100 mcgs of epi...takes a lot of discipline and experience.

Type 2 protamine reactions are anaphylactoid or anaphylactic reactions, so epi is the right answer.

Type 1 reactions are histamine release from mast cells, aka same as vancomycin red man syndrome, same mechanism, so epi is again a good answer.

Type 3 protamine reactions ... epi again.


I tell residents they should get some practice using dilute epi as just a plain vasopressor in ordinary cases where they might otherwise use ephedrine. To get a feel for what 5 or 10 or 20 mcg at a time does. Remove the mystique from it. Many people think of it as an "ACLS drug" and therefore reach for it late, or in much larger doses than needed.

 

[dchz]

Type 2 protamine reaxtions are anaphylactoid or anaphylaxtic reactions, so epi is the right answer.

Type 1 reactions are histamine release from mast cells, aka same as vancomycin red man syndrome, same mechanism, so epi is again a good answer.

Type 3 protamine reactions ... epi again.


I tell residents they should get some practice using dilute epi as just a plain vasopressor in ordinary cases where they might otherwise use ephedrine. To get a feel for what 5 or 10 or 20 mcg at a time does. Remove the mystique from it. Many people think of it as an "ACLS drug" and therefore reach for it late, or in much larger doses than needed.

I cannot reaffirm enough what an eye opener this was when i was a CA-1. In the normal cases it never really has a place to be given even though i have drawn it up a few times, i've never had to push it.

It was until i was doing a liver and then on my CT rotation that i regularly push the drug. Removing the mystique is the first step to competency.

Although i have had a CT attending that adds 1g calcium to protamine drips and claims all his type 3 reactions have gone away in the last 20 years.

 

[IlDestriero]

what? i just make my own epi bag and hang it. it takes barely any time. we have plenty of epi vials in our carts

If you have the supplies and the time that's easy.
I have a lot of little patients and no 100cc bags, so I can't just squirt a vial in there, spike it and let it go on a microdripper anymore.


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Il Destriero

 

[nimbus]

Type 2 protamine reaxtions are anaphylactoid or anaphylaxtic reactions, so epi is the right answer.

Type 1 reactions are histamine release from mast cells, aka same as vancomycin red man syndrome, same mechanism, so epi is again a good answer.

Type 3 protamine reactions ... epi again.


I tell residents they should get some practice using dilute epi as just a plain vasopressor in ordinary cases where they might otherwise use ephedrine. To get a feel for what 5 or 10 or 20 mcg at a time does. Remove the mystique from it. Many people think of it as an "ACLS drug" and therefore reach for it late, or in much larger doses than needed.

Epi in the right dose works for just about everything. It is God's inochronopressor.

 

[dhb]

I've had one case to latex under spinal: tachycardia, confusion and swelling was intubated and responded well to epi.
One i helped out on and was treated by sternotmy (it was a resynchronising pace maker and they initially thought of a perforation).
One i heard about, i think it was rocuronium and needed 17mg of epi.

 

[deleted162650]

Epi tends to be the right answer anytime someone is trying to die on you regardless of etiology.

 

[MirrorTodd]

I've had one case to latex under spinal: tachycardia, confusion and swelling was intubated and responded well to epi.
One i held out on and was treated by sternotmy (it was a resynchronising pace maker and they initially thought of a perforation).
One i heard about, i think it was rocuronium and needed 17mg of epi.

Holy crap!

 

[fakin' the funk]

If the reactions occurred shortly after induction, how do you know which medication caused it? Were the patients tested afterward?

One of those roc cases I was wrong, it was actually cefazolin. To answer your question:

1. Lidocaine, propofol, sevoflurane, isosulfan blue. No testing.
2. Propofol, rocuronium, cefazolin, desflurane. Testing confirmed cefazolin.
3. Lidocaine, propofol, rocuronium, desflurane. No testing.

 

[Sonny Crocket]

Had two cases of rocuronium induced anaphylaxis. Gave epi which helped. But noticed immediate improvement in hemodynamics once bridion was given.

 

[anbuitachi]

Interesting ,

 

[2010houston]

Necrobump - for those who have dealt with these. Obviously epi infusion is treatment of choice …. But do you usually (ha to usually, hope we all individually only have to deal with this once or twice) have to go to CRAZY high levels on your epi gtt? Had one recently where we were going way past what I’ve ever done elsewhere, but patient would tank precipitously without it.

 

[Dr. Rude]

Type 2 protamine reactions are anaphylactoid or anaphylactic reactions, so epi is the right answer.

Type 1 reactions are histamine release from mast cells, aka same as vancomycin red man syndrome, same mechanism, so epi is again a good answer.

Type 3 protamine reactions ... epi again.


I tell residents they should get some practice using dilute epi as just a plain vasopressor in ordinary cases where they might otherwise use ephedrine. To get a feel for what 5 or 10 or 20 mcg at a time does. Remove the mystique from it. Many people think of it as an "ACLS drug" and therefore reach for it late, or in much larger doses than needed.

There are two types of Protamine reactions. Some hypotension and OMFG.

 

[deleted875186]

If you have the supplies and the time that's easy.
I have a lot of little patients and no 100cc bags, so I can't just squirt a vial in there, spike it and let it go on a microdripper anymore.


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Il Destriero

Put 1 mg in a one liter bag and run at the rate mcg/min as ml/min

 

[woopedazz]

Necrobump - for those who have dealt with these. Obviously epi infusion is treatment of choice …. But do you usually (ha to usually, hope we all individually only have to deal with this once or twice) have to go to CRAZY high levels on your epi gtt? Had one recently where we were going way past what I’ve ever done elsewhere, but patient would tank precipitously without it.

I've had one to cephazolin under a spinal with no sedation onboard. I emptied vials of adrenaline into him. He pulled his jelco out and tried to hop off the bed as he aspirated, bronchospasmed and brady'ed within seconds of the ceph hitting the vein. Avoided CPR/awareness/any long-term sequelae, but was a nightmare at the time.

Had one to Patent Blue Dye under GA with an LMA in. Much slower and insidious/unclear onset and just a prolonged refractory hypotension with some spasm and rash. Hardly needed any adrenaline for that one.

I've given adrenaline extremely early after parecoxib/ondansetron reactions and both ended up being positive to skin test and tryptase, but I'm relatively certain they were both false positives. Ondansetron has a lot of those and parecoxib was probably one of those weird non-IgE mediated anaphylaxis related to IgM/compliment or something that your can get with sulpha drugs.

If it ends up being anaphylaxis, you're gonna be pissed off for missing the stabilising effects of early adrenaline. I've been liberal 4 times with good results (even though 2 were a probably overzealous/defensive). I'd prefer that than the other way

 

[2Fast2Des]

I've only had an oh **** moment when giving FFP on a bleeding pt and the pressures tanked, peak pressures went up, desaturation, no rash noted, ephedrine and phenylephrine were doing jack. Thought it was transfusion rxn or something and got back stabilisation with levo and maybe some epi. All the post labs didn't indicate any sequela of transfusion rxn and even compared the sample of the FFP bag. Wasn't sure what to make of it then, I think tryptase was negative when drawn in Pacu as well. Scary stuff when it happens though. I've had a colleague had acute bronchospasm in patient with probably unmanaged asthma after induction and intubation, patient turned blue and no air movement eventually epi gtt stabilized that as well, and surgeon wondering why the case was canceled lol

 

[nimbus]

We had a patient who developed tombstone ST elevations with profound hypotension (SBP in the 40s) in the midst of a THR under GA. My partner was doing the case and asked the surgeon to close quickly while he resuscitated the patient. The presumption at that time was that he was having a stemi from coronary disease. He was taken to Cath lab later that day and found to have normal coronaries. I ended up inheriting that patient for completion of his procedure several days later and placed a preinduction Aline but not much different otherwise. We were still unsure of what happened during his first trip to the OR. After positioning and during the site prep, I gave the traditional ancef blessing at which point he again tanked his bp to the 40s with tombstone ST elevations. But this time, since he wasn’t draped yet, we noticed he was covered in pink welts. He stabilized with a couple of epi boluses and an epi infusion and we had a diagnosis so we decided to go ahead and complete the procedure instead of bringing him back to the OR a 3rd time. He went to icu postop for continued monitoring and ended up doing well. Tryptase was massively positive.

 

[HalO'Thane]

Necrobump - for those who have dealt with these. Obviously epi infusion is treatment of choice …. But do you usually (ha to usually, hope we all individually only have to deal with this once or twice) have to go to CRAZY high levels on your epi gtt? Had one recently where we were going way past what I’ve ever done elsewhere, but patient would tank precipitously without it.

If the hypotension is refractory to Epi you can consider Vasopressin as an adjunct. This is part of the Critical Events Checklist for the treatment of anaphylaxis from the Society of Pediatric Anesthesia. Based on the etiology of anaphylactic shock this makes sense as you are dealing with profound vasodilation.

 

[narcusprince]

I can speak to anaphylaxis from two standpoints as a anesthesiologist and as a patient. Went into anaphylaxis twice from an insect local to Virginia coast. The symptoms are as follows intense itching facial swelling and hypotension(felt like someone had pulled everything out of my rectum). I got to the ER and was hypotensive, difficult breathing. Nothing else worked other than epi. I recovered rapidly after the epi.

As a physician I had a case on induction. Hypotensive tachycardic with high peak airway pressures. Presumptive anaphylaxis pushed epi, **** got better. 20-30 mcgs of epi. Gave H1 and H2s and steroids. Observed 6 hrs in pacu. Sent home with instructions to return to local ER if symptoms resume.
I wonder though with any case of intraoperative anaphylaxis should we discharge home with epi pens after observation?

 

[GassYous]

I can speak to anaphylaxis from two standpoints as a anesthesiologist and as a patient. Went into anaphylaxis twice from an insect local to Virginia coast. The symptoms are as follows intense itching facial swelling and hypotension(felt like someone had pulled everything out of my rectum). I got to the ER and was hypotensive, difficult breathing. Nothing else worked other than epi. I recovered rapidly after the epi.

As a physician I had a case on induction. Hypotensive tachycardic with high peak airway pressures. Presumptive anaphylaxis pushed epi, **** got better. 20-30 mcgs of epi. Gave H1 and H2s and steroids. Observed 6 hrs in pacu. Sent home with instructions to return to local ER if symptoms resume.
I wonder though with any case of intraoperative anaphylaxis should we discharge home with epi pens after observation?

How are you familiar with that feeling?

 

[Drwine]

Nothing else to add clinically that wasn't covered except don't forget to dray serum tryptase to confirm and get an allergist involved once the patient recovers.

Usefulness and Limitations of Sequential Serum Tryptase for the Diagnosis of Anaphylaxis in 102 Patients

Abstract. Background: The diagnosis of anaphylaxis is based on clinical history since no reliable biological marker is currently available to confirm the diagnosis. Objective: It was the aim of this study to determine sequential serum tryptase concentrations during anaphylaxis and to evaluate...

www.karger.com

 

[coffeebythelake]

Nothing else to add clinically that wasn't covered except don't forget to dray serum tryptase to confirm and get an allergist involved once the patient recovers.

Usefulness and Limitations of Sequential Serum Tryptase for the Diagnosis of Anaphylaxis in 102 Patients

Abstract. Background: The diagnosis of anaphylaxis is based on clinical history since no reliable biological marker is currently available to confirm the diagnosis. Objective: It was the aim of this study to determine sequential serum tryptase concentrations during anaphylaxis and to evaluate...

www.karger.com

Tryptase I believe can be elevated in both anaphylactic and anaphylactoid reactions, but high levels tend to favor the former

 

[appcan]

Has anyone changed their management/threshold for diagnosing anaphylaxis based on NAP6?

 

[woopedazz]

Tryptase I believe can be elevated in both anaphylactic and anaphylactoid reactions, but high levels tend to favor the former

Yeah, the non-IgE reactions tend to be less severe and have a lower peak tryptase.

There's no such thing as anaphylactoid reactions anymore. The word got deleted years ago, but for some reason some anaesthesia books are decades behind the times.

Anaphylaxis is a syndrome resulting from the release of mediators from mast cells, basophils and recruited inflammatory cells. It may be allergic or non-allergic. And if allergic it may be IgE mediated or non-IgE mediated.