Intraoperative Anaphylactic Shock Research Articles

Case Report of Intraoperative Anaphylactic Shock and Post-Operative Methemoglobinemia-Cetrimide induced during Hepatic Hydatid Cyst Surgery

Hydatid cyst is a parasitic infection most commonly localized in the liver. They may not be diagnosed early because they remain asymptomatic at small sizes and may reach large sizes at the time of diagnosis. In this situation, compression symptoms may occur and they may present with serious complications such as rupture and anaphylactic shock, which are rare. Treatment methods are determined by classification according to the imaging techniques used in the diagnosis.

ANAPHYLACTIC SHOCK DURING HYDATID CYST SURGERY : CASE REPORT

Intraoperative anaphylactic shock is an unusual complication. Different causes can be involved. Surgery of hydatid cyst is rarely responsible. About a case report of anaphylactic shock due to hydatid cyst surgery, the authors discuss the mechanisms, principles of treatment, and prevention measures of this complication.

Anaphylactic Shock after Patent Blue Dye Injection

Intraoperative anaphylactic shock is an unusual complication. About a case report a severe anaphylactic reaction to Patent Blue (PB) dye used in sentinel node biopsy for lymphatic mapping during breast cancer surgery to stage the axilla, the authors discuss the mechanisms, principles of treatments, and prevention measures of this complication.

Intraoperative anaphylactic shock caused by TachoSil<sup>®</sup> tissue sealing sheet - Case report

Intraoperative anaphylactic shock caused by TachoSil<sup>®</sup> tissue sealing sheet - Case report

Intraoperative Anaphylactic Shock Related to Fibrin Glue Application during Video-Assisted Thoracoscopic Surgery

Intraoperative Anaphylactic Shock Related to Fibrin Glue Application during Video-Assisted Thoracoscopic Surgery

Intraoperative Anaphylactic Shock Following Cefuroxime-Axetil Routine Test Case report and literature review

Approximately 72% of patients with anaphylaxis present cardio-vascular manifestations, with only few reported cases of cardiogenic shock and cardiac arrest. Cephalosporins are the most used antibiotics for prophylaxis in the perioperative period with a prevalence of allergic reactions between 1-3%. Cefuroxime, a second-generation semisynthetic cephalosporin, presents relatively rare anaphylactic reactions (0.015%). Kounis syndrome is characterized by appearance of acute coronary syndrome in the presence of platelets, basophils or mast cells activation, due to an allergic reaction, hypersensitivity, anaphylactic reaction or shock. We report a rare case of a 53-year-old female patient with intraoperative anaphylactic shock following Cefuroxime-axetil routine test, complicated with Kounis syndrome and finally with cardiac arrest.

A case of intra-operative anaphylactic shock in hepatic hydatidosis with inadequate chemotherapy and proximity to hepatic vessels

Incidence of intraoperative Hydatid anaphylaxis is 0.2-3.3% Reporting of such rare cases is crucial for future reference and study. 52 years old lady presented with hepatic hydatidosis. Computed Tomography showed 2 cystic lesions; one in segment 6, 7 in proximity to right hepatic vein; multiseptated cyst with multiple daughter cysts in segment 4 adjoining the middle hepatic vein with intracystic vessel. No rupture seen. Preoperatively she was prescribed Albendazole 400mg twice-daily for 3months. She was given Hydrocortisone before surgery. 10% povidone iodine mops to prevent intraperitoneal spillage and hypertonic saline used to flush the cyst. One hour after anesthesia when the Segment IV cyst close to middle hepatic vein was punctured she had anaphylactic shock, resuscitated. Marsupialization of both the cysts with omentoplasty and intracystic drains done. She recovered well and discharged with Albendazole for 1 month. Growing cyst produces complex echinococcal antigens, increased cellular immune response, Th2 balanced with Th1; elevated immunoglobulin levels. In dead cysts Th2 responses drop rapidly. Albendazole 10mg/kg for 3 months causes good cyst wall degeneration, less viability of protoscoleces and cyst, less echinococcal antigen production. After the surgery we found that she had stopped albendazole in the preoperative period, which she did not reveal pre-operatively fearing delay in surgery. Inadequate albendazole, close proximity of cysts to vascular structures with high intracystic pressure would have predisposed to develop anaphylactic shock during cyst handling. Preoperative Albendazole can reduce anaphylaxis, morbidity and mortality due to hydatid, making hydatid surgery safer.

Anaphylactic bronchospasm during general anesthesia is not related to asthma.

In the general population, a history of asthma (HA) is associated with a higher risk of mortality of anaphylactic shock (AS), but it is unknown whether this association remains valid for intra-operative AS. The goal of this retrospective study was to investigate whether a HA was associated with a higher risk of bronchospasm during intra-operative AS. We analyzed 106 patients (January 2009-December 2012) with intra-operative AS: 57% of them had a confirmed IgE-mediated reaction and 27% had a HA. On logistic regression, the only factor statistically associated with bronchospasm was a neuromuscular blocking drug, with both IgE- or non-IgE-mediated reactions. These results suggest that the mechanisms of bronchospasm in AS may be different from those of asthma and that, in the presence of bronchospasm during anesthesia, AS should be considered to be the most likely cause.

刺青時に感作したと思われたlatexによる術中アナフィラキシーショックの1例

症例は51歳，男性．全身に広範な刺青を有する患者．直腸癌に対し低位前方切除を施行中，突然の血圧低下，頻脈，顔面紅潮をきたした．アナフィラキシーショックを疑い，手術を中止した．Epinephrine投与などによりバイタル安定し改善を得た．術後検査でラテックスに対する特異的IgE抗体陽性であり，ラテックスアレルギーを考え，ラテックスフリー環境下で再手術を行い，問題なく手術を終了しえた．ラテックスは術中アナフィラキシーの原因の一つであり，文献報告が散見される．一般に，頻回に手術や医療処置を受ける患者に加え，医療従事者や製造業などゴム手袋着用頻度の多い群でリスクが高いとされるが，本症例はラテックスアレルギーのハイリスク群には該当せず，刺青の長期に渡る作成過程でラテックスに感作した可能性を考えた．

術中にアナフィラキシーショックをきたしたラテックスアレルギーの1例

症例は70歳，男性．胃癌（T1b（SM），N0，M0，H0，P0，cStage IA）に対し，腹腔鏡下胃全摘術を施行した．既往に慢性蕁麻疹，バリウムとニフレックによるアナフィラキシーがあった．術前の血清ラテックス抗原特異的IgE抗体は陰性だった．術中，標本摘出と再建のため小開腹を行うと，血圧の急激な低下と顔面紅潮を認めた．ラテックスによるアナフィラキシーショックを疑い，直ちに抗ショック療法と手袋の変更を行い患者の状態は改善した．手術は無事終了し，術後経過は良好だった．術後血清ラテックス抗原特異的IgE抗体は陽性となった．本病態の発症を未然に予想することは非常に困難であり，発症した際には本疾患を鑑別に挙げ，適切な対応をすることで，生命にかかわる事態は避けられると考えられた．

Unexpected death: Anaphylactic intraoperative death due to Thymoglobulin carbohydrate excipient

Anaphylactic shock is a life-threatening allergic response characterized by severe hypotension, inducing tissue hypoperfusion with possible multi-organ failure and death. We describe the first case of fatal intra-operative anaphylactic shock due to prolonged infusion of Thymoglobulin during Orthotopic Liver Transplantation (OLT), resulting from recruitment of both mastocytes and basophils, activated and degranulated. Post-mortem serological analysis on a preserved, pre-OLT sample of the patient's blood revealed specific IgE against carbohydrate cross-reactive determinants (CCDs), such as MUXF3 and nAna c2, proving that anaphylactic reaction was triggered by the Thymoglobulin carbohydrate excipient (sugar alcohol mannitol), rather than anti-thymocyte globulin itself. Our findings are consistent with scientific data reported in the literature, where only one case of non-fatal anaphylaxis to Thymoglobulin has been described, despite the existence of proven cases of anaphylactic reaction to mannitol. This case highlights the need to pay particular attention in future not only to active substances but also to drug excipients, above all during intra-operative drug delivery. In view of the important role played by basophils in this kind of anaphylaxis, the basophil activation test (BAT) could prove useful in preventing anaphylactic death from CCDs.

Liver Hydatid Cyst Rupture Into the Peritoneal Cavity After Abdominal Trauma: Case Report and Literature Review

The aim of this study was to review the literature regarding the rupture of hydatid cysts into the abdominal cavity after trauma. We present both a new case of hydatid cyst rupture that occurred after blunt abdominal trauma and a literature review of studies published in the English language about hydatid cyst rupture after trauma; studies were accessed from PubMed, Google Scholar, EBSCO, EMBASE, and MEDLINE databases. We identified 22 articles published between 2000 and 2011 about hydatid cyst rupture after trauma. Of these, 5 articles were excluded because of insufficient data, duplication, or absence of intra-abdominal dissemination. The other 17 studies included 68 patients (38 males and 30 females) aged 8 to 76 years who had a ruptured hydatid cyst detected after trauma. The most common trauma included traffic accidents and falls. Despite optimal surgical and antihelmintic therapy, 7 patients developed recurrence. Complications included biliary fistula in 5 patients, incisional hernia in 2 patients, and gastrocutaneous fistula in 1 patient. Death occurred from intraoperative anaphylactic shock in 1 patient and gastrointestinal bleeding and pulmonary failure in 1 patient. Rupture of a hydatid cyst into the peritoneal cavity is rare and challenging for the surgeon. This condition is included in the differential diagnosis of the acute abdomen in endemic areas, especially in young patients.

A case of intraoperative anaphylactic shock treated based on a guideline for anaphylactic reaction associated with antibiotics

A case of intraoperative anaphylactic shock treated based on a guideline for anaphylactic reaction associated with antibiotics

Fatal Intraoperative Anaphylaxis Related to Aprotinin after Local Application of Fibrin Glue

To the Editor:—We report a case of intraoperative fatal anaphylaxis. The chronology of the event and the subsequent evaluation strongly point to a role of the aprotinin contained in the fibrin glue locally applied to the operating field.This letter is accompanied by an Editorial View. Please see: Moss J: Allergic to anesthetics. Anesthesiology 2003; 99:521-3.A 52-yr-old man underwent surgery for a painful lumbar disc herniation. His past medical history included a rhinoplasty, and his only other medical problem was a glaucoma treated with carteolol. After premedication with hydroxyzine 100 mg, anesthesia was induced with midazolam, propofol, and rocuronium and maintained with sufentanil and desflurane. No event occurred for 2 h until application of 0.2 ml of fibrin glue (Tissucol® Kit 500 U/ml; Baxter, Maurepas, France) on a dural tear. Blood pressure decreased immediately (60 mmHg), accompanied by a bronchospasm and a skin rash. The anesthetic agents were discontinued. The patient received hydroxyethyl-starch and intravenous epinephrine, but cardiac arrest developed. Cardiac massage was started and was soon followed by defibrillation. Stabilization of hemodynamic parameters was achieved with epinephrine infusion (epinephrine 3 mg/h). Right heart and pulmonary artery catheterism performed in the intensive care unit showed a low cardiac output with low left and right filling pressure. Despite intensive inotropic support, the patient died 48 h later from multiorgan failure.The plasma levels of histamine and tryptase were increased 2 h after initial symptoms, confirming anaphylaxis. Antiaprotinin immunoglobulin (Ig) E and antiquaternary ammoniums immunoglobulins were identified in the preoperative serum of the patient (table 1).No drugs other than those cited above had been given during the 2 h preceding the shock, except for Tissucol®. The chronology does not point to a role of neuromuscular blocking agents, because a 2-h interval had elapsed between the injection of rocuronium and the shock. Our patient had specific IgE against quaternary ammoniums (detected on his preoperative stored plasma), but this has little predictive value because antiquaternary ammoniums IgE are present in 10% of the population without allergic reaction to neuromuscular blocking agents. 1An allergic reaction to latex may occur at any time during surgery, but the negativity of antilatex IgE in the preoperative serum does not support this hypothesis in our case. The chronology of events and the presence of antiaprotinin IgE in the preoperative serum strongly argue in favor of an allergic mechanism induced by fibrin glue.Fibrin glue is effective for hemostasis and sealing of tissue wounds but has been associated with severe anaphylactic reactions. 2Since 1990, Tissucol® has been composed of human coagulation factors and bovine aprotinin. The aprotinin role is to delay the destruction of the glue by fibrinolysis. None of the allergic cases following exposure to fibrin glue related to human coagulation factors. Bovine aprotinin was therefore held responsible. 3More than 100 cases of allergy to intravenous aprotinin have been published, essentially after reexposure to the drug. 4,5In our patient, the antiaprotinin IgE level was moderately positive, indicating previous sensitization. Cases of allergy after local application of the product are rare, and our case is the first related death reported. A case similar to ours was described after neurosurgery with local injection of fibrin glue for closure of a liquor fistula, which resulted only in a generalized skin rash. 6After further enquiry, we discovered that fibrin glue had been applied during the previous rhinoplasty 5 yr before. It has been demonstrated in cardiovascular surgery that locally given aprotinin results in a 10% 12-month prevalence of IgG antibodies. 7On the other hand, it has been observed in cardiovascular surgery that even a careful research of exposure history is not very sensitive to identify patients with aprotinin-specific antibodies. 8In case of known previous exposure to aprotinin, a preoperative allergologic workup is usually performed. However, the predictive value of the tests (prick-test, specific antiaprotinin IgG or IgE) has not been studied for aprotinin local application. Because the prevalence of reactions to aprotinin is higher in patients with a reexposure interval less than 6 months, such a short interval should be considered a relative contraindication to fibrin glue application. 5This is the first report of a fatal case of intraoperative anaphylactic shock related to local aprotinin. Because the preoperative questioning to investigate previous exposure to fibrin glue is difficult, and because an allergologic workup cannot be performed in every patient, the liberal use of fibrin glue must be weighed in relation to the risk of allergy.

Anesthesiologic pecularities in patients with latex allergy

Immediate-type hypersensitivity due to natural rubber (latex) products is an increasing problem for the anaesthetist, because a major part of products used for anaesthesia contains natural rubber. If the patient has a positive history of allergic symptoms after contact to natural rubber like urticaria, bronchospasm or anaphylaxis, preoperative skin tests, in vitro tests, and if necessary even the latex-glove-wearing test should be performed. If preoperative diagnosis of natural latex allergy is established, latex free anaesthesia is strictly recommended; otherwise life-threatening complications may ensue. Accordingly, we report on a patient who developed intraoperative anaphylactic shock following exposure to natural latex. In addition to the treatment with drugs, latex-containing products should be immediately replaced by latex-free ones, in particular all persons should put on latex-free gloves. For prevention of anaphylactic episodes in sensitized patients the reader is provided with an exemplary list of latex-free products for anaesthesia. Because the incidence of immediate-type reactions to latex is still increasing, intraoperative occurrence of an anaphylactic reaction to an unknown agent is likely to be due to allergy to natural rubber.

Prospective study of risk factors in natural rubber latex hypersensitivity

Five hundred sixty-nine subjects routinely underwent skin prick tests for latent sensitization to latex. The study of risk factors included skin tests to inhalant allergens, to diagnose atopy, and a questionnaire aimed at revealing frequent exposure to latex such as the wearing of gloves, multiple surgical procedures, or urinary catheterization. The subjects were categorized into five groups: group I, subjects with no risk factor (n = 272); group II, nonatopic subjects exposed to latex (n = 73); group III, atopic subjects not exposed (n = 180); group IV, exposed atopic subjects (n = 44); and group V, subjects with a history of intraoperative anaphylactic shock caused by latex (n = 13). Twenty-five subjects had spina bifida and were in either group II (14 subjects) or group IV (11 subjects). The questionnaire identified a probable allergy to latex in 18 subjects: 16 cases were confirmed by skin test, but responses were not informative in 23 patients who were sensitive to latex. Positive prick tests to latex were obtained in 0.37% of group I, 6.85% of group II, 9.44% of group III, and 36.36% of group IV. Of the children with spina bifida, 32% had positive skin test results. As risk factors, atopy and exposure were synergistic. We recommend predictive prick tests not only in children with spina bifida but also in any atopic subject or in any patient with a history of frequent exposure to latex. Latex could be considered a habitual allergen. The use of latex urinary catheters should be avoided in patients who are catheterized on a daily basis.

Prospective study of risk factors in natural rubber latex hypersensitivity

Five hundred sixty-nine subjects routinely underwent skin prick tests for latent sensitization to latex. The study of risk factors included skin tests to inhalant allergens, to diagnose atopy, and a questionnaire aimed at revealing frequent exposure to latex such as the wearing of gloves, multiple surgical procedures, or urinary catheterization. The subjects were categorized into five groups: group I, subjects with no risk factor (n = 272); group II, nonatopic subjects exposed to latex (n = 73); group III, atopic subjects not exposed (n = 180); group IV, exposed atopic subjects (n = 44); and group V, subjects with a history of intraoperative anaphylactic shock caused by latex (n = 13). Twenty-five subjects had spina bifida and were in either group II (14 subjects) or group IV (11 subjects). The questionnaire identified a probable allergy to latex in 18 subjects: 16 cases were confirmed by skin test, but responses were not informative in 23 patients who were sensitive to latex. Positive prick tests to latex were obtained in 0.37% of group I, 6.85% of group II, 9.44% of group III, and 36.36% of group IV. Of the children with spina bifida, 32% had positive skin test results. As risk factors, atopy and exposure were synergistic. We recommend predictive prick tests not only in children with spina bifida but also in any atopic subject or in any patient with a history of frequent exposure to latex. Latex could be considered a habitual allergen. The use of latex urinary catheters should be avoided in patients who are catheterized on a daily basis.