ANGIOEDEMA REFRACTORY TO STANDARD MEDICAL MANAGEMENT: THE USE OF FRESH FROZEN PLASMA IN THE ICU SETTING TO PREVENT INTUBATION AND MECHANICAL VENTILATION

Abstract

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Angioedema is a self-limiting swelling of the lips, tongue, oropharynx, and larynx that can develop rapidly due to localized vascular vasodilation. The two main mechanisms of angioedema are histamine-mediated and bradykinin-mediated; the latter of which is a known side effect of angiotensin-converting enzyme inhibitors. Despite the two different mechanisms, angioedema is treated the same no matter the cause with steroids, epinephrine, and antihistamines. However, there is growing evidence that fresh frozen plasma (FFP) has shown beneficial results when treating refractory bradykinin-mediated angioedema caused by ACEI use. Given the risk for potential airway compromise and obstruction, FFP should be considered early to prevent the need for intubation. CASE PRESENTATION: A 51 year old male presented with acute onset lower lip swelling. He was started on lisinopril 5mg daily 2 days prior to arrival and had never been on an ACE inhibitor or ARB before. On presentation, his swelling was limited to lower lip; upper lip and tongue were not involved as well as no involvement of airway. In the ED, he was given epinephrine 0.3 mg (1:1000) IM, methylprednisolone 125 mg IV, diphenhydramine 50 mg IV, famotidine 20 mg IV. These interventions did not significantly improve patient’s status so he was admitted to the IICU for airway monitoring. His swelling was noted to advance, now involving the upper lip as well. Discussion regarding concerns for intubation were expressed. Patient at this time continued to deny any difficulty in breathing or sensation that throat was swelling. Due to increasing in noticeable swelling, decision was made to move the patient into the ICU and transfuse 2 units FFP. Resolution of symptoms was observed immediately afterwards and he did not require intubation. He was safely discharged the next morning. DISCUSSION: ACE-inhibitors limit the degradation of serum bradykinin which leads to potent vasodilation of venules. Capillary leakage causes edema of the face, mouth, oropharynx, and larynx, which if large enough, can lead to airway compromise and the need for intubation. ACE inhibitor-induced angioedema can occur in any patient at any time during their treatment course and can be difficult to differentiate from other angioedemas. FFP contains kininase-II, which breaks down bradykinin. Current guidelines still recommend steroids, antihistamines, and epinephrine as first line treatments; however, in refractory cases or those pending imminent respiratory collapse, FFP should be considered. The risk of administering FFP include allergic and transfusion reactions, infection transmission, volume overload, and delay in time of treatment. CONCLUSIONS: In this case, 2 units of FFP were given to a patient with ACEI-induced angioedema refractory to standard therapy, and we were able to successfully avoid intubation as well as limit hospital and ICU lengths of stay to 1 day. Reference #1: Saeb, A., Hagglund, K. H., & Cigolle, C. T. (2016). Using Fresh Frozen Plasma for Acute Airway Angioedema to Prevent Intubation in the Emergency Department: A Retrospective Cohort Study. Emergency Medicine International, 2016, 1-6. doi:10.1155/2016/6091510 Reference #2: Riha, H. M., Summers, B. B., Rivera, J. V., & Berkel, M. A. (2017). Novel Therapies for Angiotensin-Converting Enzyme Inhibitor–Induced Angioedema: A Systematic Review of Current Evidence. The Journal of Emergency Medicine, 53(5), 662-679. doi:10.1016/j.jemermed.2017.05.037 Reference #3: Chaaya, G., Afridi, F., Faiz, A., Ashraf, A., Ali, M., & Castiglioni, A. (2017). When Nothing Else Works: Fresh Frozen Plasma in the Treatment of Progressive, Refractory Angiotensin-Converting Enzyme Inhibitor–Induced Angioedema. Cureus. doi:10.7759/cureus.972 DISCLOSURES: No relevant relationships by Justin Bahoora, source=Web Response No relevant relationships by John Berquist, source=Web Response No relevant relationships by Sapna Kher, source=Web Response