Kosin Med J.  2018 Dec;33(3):468-476. 10.7180/kmj.2018.33.3.468.

Hypersensitivity Reaction to Perioperative Drug Mistaken for Local Anesthetic Systemic Toxicity in a Patient under Brachial Plexus Block

• Jun JY
• Kim YJ
• Kim JH
• Han JI

• KMID: 2442561
• DOI: http://doi.org/10.7180/kmj.2018.33.3.468

Abstract

Perioperative anaphylaxis, although rare, is a severe, life-threatening unexpected systemic hypersensitivity reaction. Simultaneous administration of various drugs during anesthesia, the difficulty of communicate with patients in sedation and anesthesia, and coverage of the patient with surgical drapes are considered to be factors that impede early recognition of anaphylactic reactions. It is very important to perform an intradermal skin test because antibiotics are the most common cause of perioperative anaphylaxis. We report a case of negative-intradermal skin test antibiotic anaphylaxis mistaken for local aesthetic systemic toxicity without increase of serum tryptase for confirmative diagnostic biomaker during surgery under brachial plexus block. It is not possible to exclude the danger of anaphylaxis completely, even if it is negative-intradermal skin test and normal tryptase level. Therefore, anesthesiologists should be closely monitored and treated early for antibiotics related hypersensitive reaction, like other medicines during anesthesia.

Keyword

Anaphylaxis; Anesthesia; Antibiotics; Local anesthetic systemic toxicity Skin test; Tryptase

MeSH Terms

Anaphylaxis
Anesthesia
Anti-Bacterial Agents
Brachial Plexus Block*
Brachial Plexus*
Humans
Hypersensitivity*
Skin Tests
Surgical Drapes
Tryptases
Anti-Bacterial Agents
Tryptases

Figure

• 

  Fig. 1 Changes in vital signs during anesthesia (Axillary BPB). From about 5 minutes after antibiotic administration, instability of the vital signs was observed, which was followed by tachycardia, blood pressure was abrupt dropped to 50/32 mmHg and rapid fluid hydration was delivered with emergency medication including with ephedrine, atropine, epinephrine, steroid and antihistamine. As a result, the vital signs gradually stabilized, and the operation could be completed.

Reference

1. Holgate ST. Church MK, Martinez FD, Broide DH, editors. Allergy. 4th ed. London: Elsevier publisher;2012. p. 331–346.

2. Galvão VR, Giavina-Bianchi P, Castells M. Perioperative anaphylaxis. Curr Allergy Asthma Rep. 2014; 14:452.

3. Gurrieri C, Weingarten TN, Martin DP, Babovic N, Narr BJ, Sprung J, et al. Allergic reactions during anesthesia at a large United States referral center. Anesth Analg. 2011; 113:1202–1212.

4. Kuhlen JL Jr, Camargo CA Jr, Balekian DS, Blumenthal KG, Guyer A, Morris T, et al. Antibiotics Are The Most Commonly Identified Cause of Perioperative Hypersensitivity Reactions. J Allergy Clin Immunol Pract. 2016; 4:697–704.

5. Lee SH, Park HW, Kim SH, Chang YS, Kim SS, Cho SH. et al. The Current Practice of Skin Testing for Antibiotics in Korean Hospitals. Korean J Intern Med. 2010; 25:207–212.

6. Mertes PM, Alla F, Tréchot P, Auroy Y, Jougla E. Groupe d'Etudes des Réactions Anaphylactoïdes Peranesthésiques. Anaphylaxis during anesthesia in France: an 8-year national survey. J Allergy Clin Immunol. 2011; 128:366–373.

7. Fasting S, Gisvold SE. Serious intraoperative problems--a five- year reviews of 83,844 anesthetics. Can J Anaesth. 2002; 49:545–553.

8. Mertes PM, Laxenaire MC. Allergy and anaphylaxis in anaesthesia. Minerva Anestesiol. 2004; 70:285–291.

9. Saager L, Turan A, Egan C, Mascha EJ, Kurz A, Bauer M, et al. Incidence of Intraoperative Hypersensitivity Reactions: a registry analysis. Anesthesiology. 2015; 122:551–559.

10. Lieberman P. Anaphylactic reactions during surgical and medical procedures. J Allergy Clin Immunol. 2002; 110:S64–S69.

11. Laroche D, Lefrançois C, Gérard JL, Dubois F, Vergnaud MC, Guéant JL, et al. Early diagnosis of anaphylactic reactions to neuromuscular blocking drugs. Br J Anaesth. 1992; 69:611–614.

12. Kim KN, Kim DW, Sin YH, Oh SY. Anaphylactic shock caused by an intradermal skin test-negative antibiotic during general anesthesia. Anesth Pain Med. 2016; 11:260–263.

13. Weinberg G, Barron G. Local anesthetic systemic toxicity (LAST): notgone, hopefully not forgotten. Reg Anesth Pain Med. 2016; 41:1–2.

14. Barrington MJ, Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. 2013; 38:289–299.

15. Di Gregorio G, Neal JM, Rosenquist RW, Weinberg GL. Clinical presentation of local anesthetic systemic toxicity: a review of published cases, 1979 to 2009. Reg Anesth Pain Med. 2010; 35:181–187.

16. Chazalon P, Tourtier JP, Villevielle T, Giraud D, Saissy JM, Mion G, et al. Ropivacaine-induced cardiac arrest after peripheral nerve block: successful resuscitation. Anesthesiology. 2003; 99:1449–1451.

17. McCutchen T, Gerancher JC. Early intralipid therapy may have prevented bupivacaine-associated cardiac arrest. Reg Anesth pain Med. 2008; 33:178–180.

18. Muraro A, Roberts G, Worm M, Bilo MB, Brockow K, Fernandez Rivas M, et al. Anaphylaxis: guidelines from the European Academy of Allegy and Clinical Immunology. Allergy. 2014; 69:1026–1045.

19. Mertes PM, Laxenaire MC, Alla F. Groupe d'Etudes des Réactions Anaphylactoïdes Peranesthésiques. Anaphylactic and anaphylactoid reactions occurring during anesthesia in France in 1999-2000. Anesthesiology. 2003; 99:536–545.

20. Yoon SY, Park SY, Kim S, Lee T, Lee YS, Kwon HS, et al. Validation of the cephalosporin intradermal skin test for prediction immediate hypersensitivity: a prospective study with drug challenge. Allergy. 2013; 68:938–944.