Redness around neck post-induction

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jope

jope

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I was quizzed by a staff today regarding why a patient would develop red patches after induction which were obvious around the neck area and what was it. They did not appear to be hives.

Induction drugs were droperidol 1.25 for PONV prophylaxis, midazolam 2 mg, fentanyl 50 units, propofol with some lidocaine mixed in. It seemed to have occurred in patients with rocuronium or sux.

Anyone here know if any of the drugs used commonly during induction causes an immediate rash? I've only found that roc can cause a rash as an adverse effect.
 
Back in the day, we used to call this a "pentothal rash". We would see it frequently enough. Always went away in a few minutes without hemodynamic problems. Always around the upper chest and neck.

Am now, less frequently, seeing it with prop also. Goes away no problem, no treatment needed.

Except once, I had a 19y male who got whole body hives after propofol induction. A little Benadryl, they went away. Stayed away from prop infusion for the case, of course.

Must be a histamine release thing, but I don't know for a fact what is going on...Like some many things in medicine.
 
Yes, it is very common and I don't think we really know why it happens.
I have seen it with STP, Propofol and even Etomidate in combination with Sux,Roc, Vec, Pancuronium, Mivacurium, Atracurium...
Interestingly I don't remember seeing it when no muscle relaxant was used.
It could be Histamine release in the upper body because the induction agent or muscle relaxant could have a transient higher concentration in the upper body after injection through an upper extremity vein.
 
I observed a 10 hour case yesterday (total lareyngectomy and node dissection, in a 50 yo male, active smoking, Hep B+, previous trach for a subglottal cancer) and actually pointed out the first spot on his chest, which seemed to look just like a mosquito bite after induction. Then a minute or two later he had 10 across his upper torso. Nothing was given and it resolved. Induction with propofol.

Oh, after getting preoxygenated, dude who spoke minimal english and used sister for translation during pre-op, coughed and coughed, only to hand a piece of chewing gum to the scrub nurse...

Case was cancelled by my mentor citing the debate about gum and full stomach in the literature. Then, after thinking things over, no GERD, reflux, other significant co-morbidities, case went off without a hitch. Aside from me not sitting for 1 min over the next 10 hours standing next to anesthesia. 😉

D712
 
doctor712 said:
I observed a 10 hour case yesterday (total lareyngectomy and node dissection, in a 50 yo male, active smoking, Hep B+, previous trach for a subglottal cancer) and actually pointed out the first spot on his chest, which seemed to look just like a mosquito bite after induction. Then a minute or two later he had 10 across his upper torso. Nothing was given and it resolved. Induction with propofol.

Oh, after getting preoxygenated, dude who spoke minimal english and used sister for translation during pre-op, coughed and coughed, only to hand a piece of chewing gum to the scrub nurse...

Case was cancelled by my mentor citing the debate about gum and full stomach in the literature. Then, after thinking things over, no GERD, reflux, other significant co-morbidities, case went off without a hitch. Aside from me not sitting for 1 min over the next 10 hours standing next to anesthesia. 😉

D712
Click to expand...

Please stop.
 
Actually, I believe this phenomenon only occurs in patients who shop at Walmart and attend NASCAR events.
 
BobBarker said:
Please stop.
Click to expand...
I feel you BobBarker. Docter712 you using the term standing by anesthesia can be perceived by some as degrading(not by me). Also, your pre-med not even in medical school. I would focus more on the pre-med issues IE am I going to get into medical school, shouldn't I be learning A+P, immunology, micro that kind of stuff. I know your interested in anesthesia but come on with all the OR stories. I find it slightly annoying focus on being a premed bub. Good luck with getting in, I hope you become an anesthesiologist.
 
Planktonmd said:
Yes, it is very common and I don't think we really know why it happens.
I have seen it with STP, Propofol and even Etomidate in combination with Sux,Roc, Vec, Pancuronium, Mivacurium, Atracurium...
Interestingly I don't remember seeing it when no muscle relaxant was used.
It could be Histamine release in the upper body because the induction agent or muscle relaxant could have a transient higher concentration in the upper body after injection through an upper extremity vein.
Click to expand...

Is the histamine reaction much more common with atracurium? We often get these sort of "one-liner" anesthesia questions on our ABSITE, and most surgery study guides point out atracurium as specifically being prone to histamine reaction. Is that true in real life, or just tests?

Also, we had a few etomidate questions on the ABSITE last year....and there's a mandatory "one-liner" about pancuronium causing tachycardia. I will admit that I have near-zero knowledge of these drugs and their real-life usage, but simply memorize some facts to get a good percentile score once a year....
 
I hear ya Narcu, about "standing next to Anesthesia." Maybe I should have said something more appropriate as in, "Observing the resident and attending anesthesiologists..." It didn't strike me I was being offensive as it's always a thrill for me. Noted.

As for focusing on all the pre-med stuff, yeah, that's basically my entire life right now, Narc. Isn't part of that getting in, getting clinical exposure though? D amned if you do, d amned if you don't. Getting into the OR and sharing interesting stories, from my POV, I don't know, I feel Barker was really squelching enthusiasm, frankly. The academic attendings I work directly for welcome me into the OR, and I find that an important part of being a pre-med, apparently they do as well, or they wouldn't be so generous.

I shared the same story with Jet and couple other friends, seemed to be QUITE differently received, but then again they're friends. Not sure why getting into med school would preclude telling fun stories and sharing my pre-med anesthesia experiences here, in the small amounts I share them in fact. A+P, Immunology and Micro are daily activities for me. Whether staring at a book, or viewing a two minute white board lecture I get in the OR from same anesthesiologists.

I do know that you're rooting for me to get in Narc, I feel that, and I appreciate that.

If anyone else finds my experiences of stories offensive/annoying/intrustive enough to call me Bub and ask me to refrain, I'm listening...

D712
 
Last edited:
SLUser11 said:
Is the histamine reaction much more common with atracurium? We often get these sort of "one-liner" anesthesia questions on our ABSITE, and most surgery study guides point out atracurium as specifically being prone to histamine reaction. Is that true in real life, or just tests?

Also, we had a few etomidate questions on the ABSITE last year....and there's a mandatory "one-liner" about pancuronium causing tachycardia. I will admit that I have near-zero knowledge of these drugs and their real-life usage, but simply memorize some facts to get a good percentile score once a year....
Click to expand...

Atracurium does cause histamine release if used as a large bolus for induction while Cisatracurium does not have this problem.
Pancuronium has some anticholinergic properties and can cause some tachycardia on induction.
 
Its just too much. You observing for 10 hours is unnecessary and probably unwanted by your attending (hint: most anesthesiologists will direct you to find a stool.) As a specialty, people who go into anesthesia usually aren't interested in self-flagellation. Not trying to be a jerk or anything, but every specialty has a certain personality type, and your post lends me to think you would probably be a better fit in urology. Not dogging on you and not trying to make a dick joke..
 
BBarker, Come on, get over yourself. You've pegged me as a Urologist from over the web?

Sigh.

Lunch, stools and the like were offered, same with surgeons having me watch over their shoulders for hours at a time. So, when the Chair or PD has a cool case he wants to bring you in on, for 2 hours or 10 hours, you say Yes. And when, at the end of the 10 hour day they tell you, "Be back 7am tomorrow..?" I think I'm pretty decent at reading how things are going for me with these mentors. They've also put me on the payroll, given me a job, and been supportive beyond my imagination. Agreed, had I known it was going to be a 10 hour case, I'd have raised an eyebrow, but guess what, I'm not going to be the guy, even the observer, who bails before the day is over. Period. One doesn't observe because he needs to, as you say, but because he wants to. It's not school for me just yet.

So, thanks for the opinion on personality types, but I think you've confused self-flagellation with enthusiasm. I'm doing just fine with the personality types I've found in this and other anesthesia experiences, and it's mutual, or I wouldn't be doing whatever it is that I'm doing that's annoying you so much.

MOVING. ON. Hope to get back on topic...

D712
 
doctor712 said:
Case was cancelled by my mentor citing the debate about gum and full stomach in the literature. Then, after thinking things over, no GERD, reflux, other significant co-morbidities, case went off without a hitch. Aside from me not sitting for 1 min over the next 10 hours standing next to anesthesia. 😉

D712
Click to expand...

This dude (the guy who nearly cancelled the case) makes the rest of us look like *****s. How is the 'gum-effect' any different than an 8 hr npo diabetic...gunna cancel that one too cause u read about delayed gastric emptying
 
jope said:
I was quizzed by a staff today regarding why a patient would develop red patches after induction which were obvious around the neck area and what was it. They did not appear to be hives.

Induction drugs were droperidol 1.25 for PONV prophylaxis, midazolam 2 mg, fentanyl 50 units, propofol with some lidocaine mixed in. It seemed to have occurred in patients with rocuronium or sux.

Anyone here know if any of the drugs used commonly during induction causes an immediate rash? I've only found that roc can cause a rash as an adverse effect.
Click to expand...

Ive always assumed it was the sux
 
BobBarker said:
Refusing a stool and a lunch is self-flagellation.
Click to expand...

I had a quick lunch. Standing. Not far from OR, then wanted to get back to watch. The resident had the stool, not sure what else to tell you, I wasn't going to take it out from under him, even though it was offered...maybe that's your style. I should be the observer sitting when the mentor/attending walks in and sees the resident standing and me sitting 10 feet from the cart of table??? If I'm there, I wanna look, as much and as close as I can.

Anyway, REALLY wish you'd just focus on the thread more, and me less.
That's putting it kindly.

So, please, move on. You've expressed your opinion.

D712
 
I'm trying to help you. No, you shouldn't take the stool from the resident. You should go find your own stool.
 
aredoubleyou said:
This dude (the guy who nearly cancelled the case) makes the rest of us look like *****s. How is the 'gum-effect' any different than an 8 hr npo diabetic...gunna cancel that one too cause u read about delayed gastric emptying
Click to expand...

I can't speak to that, all I can say is he burnt off some steam (case cancelled, that's a full stomach...) after dude spit out gum upon getting O2 by mask for a while. Then cooled down and proceeded. I dunno, it's a teaching institution, maybe he was trying to teach the resident about the recent literature and articles about gum, who knows, it's not PP. He made a point of also mentioning to me a learning point here, despite his hierarchy at said institution, nobody is above consulting someone else, a partner down the hall, who said just do it. Things calmed down and about 3 mins later, it was still a go. It's a question for the academics here: would you give a c rap if the gum were placed in your hands?

D712
 
BobBarker said:
I'm trying to help you. No, you shouldn't take the stool from the resident. You should go find your own stool.
Click to expand...

I was enjoying the anatomy and the surgery, really couldn't peel myself away. And the CA-1 doing the case was quite the talker as it was. And the attending was in and out. Perhaps the lesson here is not to "complain" about 10 hour cases on SDN as a pre-med. The stool wasn't really that big an issue, it was just 6 hours longer than any other case I'd ever seen and frankly, I kept thinking the case would end. When the ENT said, "We'll be done in 6 more hours," I thought she was KIDDING, but she wasn't.

But I'll keep Uro in the back of my mind as I know you're just trying to help!
(that's a joke).

D712
 
Not going to lie, I initially read the title of this thread as "Rednecks, post-induction."
 
This actually happened to my patient yesterday.

Pt was a 43 old female recently dx'd with breast Ca having a nipple sparing double mastectomy with breast expander placement. She was otherwise healthy with a BMI of 25. Of note she was allergic to seafood. She was induced with midazolam, fentanyl 150, lidocaine, propofol and roc. Post intubation she had redness which the attending and I couldn't figure why, but I treated with benadryl and it went away.

I thought about quoting this thread to my attending but I changed my mind. 🙂
 
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