F120. Intraoperative neurophysiological identification of a critical life-threatening reaction

Abstract

Introduction The highest likelihood of neurologic compromise occurs during critical times of tissue and vascular structure manipulation. We report a case of neurophysiologic change after completing the critical portion of a procedure. Methods A 65 year old woman had left internal carotid artery proximal stenosis with aneurysm. She consented for endovascular therapy and listed no known drug allergies during the pre-operative process. The patient underwent successful stenting and angioplasty without complications. After completing the final post-procedure diagnostic angiogram, the anesthesiologist administered 2 grams of cefazolin just prior to closure. Within 8 min, the neuromonitoring team noted moderate global slowing on the 6-channel EEG, and a drop in the mean arterial pressure (MAP) from 70 to 24, consistent with systemic hypoperfusion. This information was conveyed to the surgeon and anesthesiologist, who were troubleshooting the arterial line under the initial assumption that the MAP decrease was technical in nature. After conferring information and confirming the lack of a palpable pulse, cardiopulmonary resuscitation was initiated with chest compressions.Given the chronology of events following administration of cefazolin and suspected anaphylactic shock, the anesthesiologist administered epinephrine (2.2 mg total) for vasoconstriction. The MAPs overshot the baseline to the 120–150 range and remained elevated for a brief period of time, but eventually returned to baseline. In addition, the anesthesiologist bolused 150 mg of propofol to decrease cerebral metabolism and lower the oxygen demand. The EEG went into near total suppression pattern but gradually returned to the intraoperative baseline over a span of thirty minutes. During this time, the catheter and guidewires were removed, and the procedure was concluded. She was noted to be moving all extremities and following commands immediately post-operation. The patient was transferred to the ICU for monitoring of clinical condition and remained intubated for 24 h for airway protection. She was extubated on post-operative day (POD) 1 and discharged at her baseline neurologic function on POD 2. Results The neuromonitoring team first identified the critical anaphylactic reaction causing systemic hypoperfusion via the neurophysiological changes and did so expeditiously resulting in cardiopulmonary resuscitation and good postoperative outcome. Conclusion This case report depicts a rare iatrogenic cause of neurologic compromise and highlights the intraoperative neuromonitoring team’s role in timely identification and resolution of complications during ”non-critical” portions of a procedure.