WHAT TO GIVE NEXT? THE CHALLENGE OF SEVERE PERIOPERATIVE DRUG REACTIONS IN PEDIATRIC PATIENTS

Abstract

<h3>Introduction</h3> Perioperative drug reactions (PODR) are rare, occurring in∼ 1:10,000 cases. For patients with ongoing surgical needs, it is challenging to select safe alternatives. <h3>Case Description</h3> An 11 yr old male with history of food allergy, environmental allergy, and well-controlled mild intermittent asthma required surgical reduction of a forearm fracture. Prior to presentation, he was clinically well. Anesthesia induction was performed with propofol, rocuronium, and morphine. Within minutes, the patient had severe bronchospasm, without hives/angioedema, leading to bradycardic arrest requiring intubation, resuscitation with epinephrine and ICU admission. Serum tryptase drawn at 30 minutes after the event was 62.5 ug/mL (normal: <10.9 ug/mL).. The following day, he tolerated vecuronium and rocuronium while intubated. He has tolerated multiple opiates since the event. The initial injury still requires surgical repair. <h3>Discussion</h3> His PODR was most likely triggered by a medication received during anesthesia induction, and clinically, rocuronium was most suspected. Mast cell depletion may explain his tolerance immediately after the event. Propofol is a rare cause of anaphylaxis but remains a possibility. Opioids are less likely as the patient has since tolerated multiple opioids. An underlying mast cell disorder must be considered. It was recommended the patient avoid rocuronium, vecuronium, and propofol until a full evaluation is completed. Cisacuronium was offered as an alternative agent to use for his acutely needed surgical repair due to the low cross-reactivity (5%) with rocuronium. Outpatient SPT testing was recommended when well. This case highlights the differential for perioperative anaphylaxis and the importance of further evaluation to determine the inciting agent.