Shimmy8

ASA Member
7+ Year Member
Sep 10, 2012
318
306
Status
Resident [Any Field]
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.
 

ranvier

I can't anesthetize a rumor.
10+ Year Member
Jul 17, 2006
248
127
Status
Attending Physician
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

It's a gas.
10+ Year Member
Apr 23, 2006
16,464
7,567
Nowhere
Status
Resident [Any Field]
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.
 
About the Ads

FFP

Just another jerk
Gold Donor
10+ Year Member
Oct 17, 2007
7,834
8,157
Status
Attending Physician
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).
 
Last edited:

IkeBoy18

ASA Member
10+ Year Member
Jul 13, 2005
694
83
Status
Fellow [Any Field]
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

10+ Year Member
Dec 2, 2008
624
292
Status
Non-Student
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

7+ Year Member
Mar 27, 2011
1,443
1,061
Status
Attending Physician
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.
 
OP
Shimmy8

Shimmy8

ASA Member
7+ Year Member
Sep 10, 2012
318
306
Status
Resident [Any Field]
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.
 

fakin' the funk

ASA Member
15+ Year Member
Aug 23, 2004
2,741
603
Status
Attending Physician
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).
 
  • Like
Reactions: ranvier

nimbus

Member
10+ Year Member
Jan 14, 2006
5,022
5,315
Status
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

Ether Man
10+ Year Member
Nov 24, 2007
7,653
7,219
The ivory tower.
Status
Attending Physician
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.


--
Il Destriero
 
About the Ads

anbuitachi

10+ Year Member
Oct 26, 2008
4,637
1,627
Utah
Status
Attending Physician
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.


--
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
 
  • Like
Reactions: AdmiralChz

pgg

Laugh at me, will they?
Administrator
10+ Year Member
Dec 15, 2005
12,425
8,947
Not home
Status
Attending Physician
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

Avoiding the Dunning-Kruger
Gold Donor
7+ Year Member
Sep 25, 2012
811
771
Unplugged
Status
Fellow [Any Field]
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

Ether Man
10+ Year Member
Nov 24, 2007
7,653
7,219
The ivory tower.
Status
Attending Physician
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.


--
Il Destriero
 

nimbus

Member
10+ Year Member
Jan 14, 2006
5,022
5,315
Status
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

Member
Lifetime Donor
10+ Year Member
Jul 12, 2006
3,984
1,211
Status
Attending Physician
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.
 
Last edited:

MirrorTodd

It's a gas.
10+ Year Member
Apr 23, 2006
16,464
7,567
Nowhere
Status
Resident [Any Field]
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!
 
  • Like
Reactions: anbuitachi

fakin' the funk

ASA Member
15+ Year Member
Aug 23, 2004
2,741
603
Status
Attending Physician
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.
 
About the Ads