ABSTRACT
In Australia, neuromuscular blocking agents are the leading cause of perioperative anaphylaxis. Current investigation of suspected anaphylaxis includes tryptase levels, serum immunoglobulin E (IgE) levels, and skin testing, including intradermal testing and skin prick testing. The gold standard for the diagnosis of a hypersensitivity reaction is a challenge test, but this poses a risk to patient safety. An alternative test, known as the basophil activation test (BAT) is a form of cellular in vitro testing using flow cytometry to measure the degree of basophil degranulation within a sample of blood following exposure to an allergen. This acts as a surrogate marker for mast cell and basophil activation, thereby identifying IgE-mediated allergy. It is most commonly used to supplement equivocal findings from initial in vitro testing to assist in confirming the diagnosis of a hypersensitivity reaction and identify the causative agent. We present a case series in which five patients with suspected anaphylaxis underwent a BAT, demonstrating its role and limitations in allergy testing within Australia.
Subject(s)
Anaphylaxis , Basophils , Neuromuscular Blocking Agents , Humans , Anaphylaxis/diagnosis , Anaphylaxis/chemically induced , Neuromuscular Blocking Agents/adverse effects , Male , Basophils/immunology , Female , Middle Aged , Basophil Degranulation Test/methods , Adult , Aged , Drug Hypersensitivity/diagnosis , Drug Hypersensitivity/immunology , Skin Tests/methods , Perioperative Period , Immunoglobulin E/blood , Immunoglobulin E/immunology , AustraliaABSTRACT
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a class of oral glucose-lowering agents commonly used for the treatment of type 2 diabetes. With increased use, there has been an increase in the incidence of the rare but life-threatening complication of euglycemic diabetic ketoacidosis. A common but underappreciated precipitant is colonoscopy. In this work, we outline the pathophysiology of the interaction between colonoscopy and SGLT2i use, the evidence regarding SGLT2i use in the periprocedural setting and Australian Diabetes Society guidelines.
Subject(s)
Colonoscopy , Diabetes Mellitus, Type 2 , Diabetic Ketoacidosis , Hypoglycemic Agents , Sodium-Glucose Transporter 2 Inhibitors , Humans , Australia , Blood Glucose/analysis , Colonoscopy/adverse effects , Diabetes Mellitus, Type 2/drug therapy , Diabetes Mellitus, Type 2/complications , Diabetic Ketoacidosis/blood , Diabetic Ketoacidosis/etiology , Diabetic Ketoacidosis/physiopathology , Diabetic Ketoacidosis/prevention & control , Glucose , Hypoglycemic Agents/adverse effects , Hypoglycemic Agents/therapeutic use , Sodium , Sodium-Glucose Transporter 2 Inhibitors/adverse effects , Sodium-Glucose Transporter 2 Inhibitors/therapeutic use , Cathartics/administration & dosage , Cathartics/adverse effects , Ketones/metabolismSubject(s)
Diabetes Mellitus, Type 2 , Pharmaceutical Preparations , Blood Glucose , Glucose , Humans , Hypoglycemic AgentsABSTRACT
BACKGROUND: Perioperative diabetic ketoacidosis (DKA) with near-normal blood glucose concentrations, termed euglycaemic ketoacidosis (EDKA), is an adverse effect associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i). Guidelines are still evolving concerning the perioperative management of patients on SGLT2i. We performed a systematic review of published reports of DKA from SGLT2i in the surgical setting to understand better the clinical presentation and characteristics of SGLT2i-associated DKA. METHODS: We searched PubMed, Embase, and ProQuest for reports of perioperative DKA involving SGLT2i up to January 2019. RESULTS: Forty-two reports of EDKA and five cases of hyperglycaemic diabetic ketoacidosis (HDKA) were identified from 33 publications. Canagliflozin was implicated in 26 cases. Presentation time varied from a few hours up to 6 weeks after operation. Precipitating factors may include diabetes medication changes, diet modifications, and intercurrent illnesses. There were 13 cases (12 EDKA and one HDKA) of bariatric surgery, 10 of them noted very-low-calorie diet regimes as a precipitating factor. No precise association between interruption of SGLT2i and the occurrence of DKA could be identified. Seven patients required mechanical ventilation, and acute kidney injury was noted in five. Five cases needed imaging to rule out anastomotic leak and pulmonary embolism, all of them revealed negative findings. Outcome data were available in 32 cases, all of them recovered completely. CONCLUSIONS: EDKA is likely to be under-recognised because of its atypical presentation and may delay the diagnosis. Understanding this clinical entity, vigilance towards monitoring plasma/capillary ketones helps in early identification and assists in the management.
Subject(s)
Diabetic Ketoacidosis/blood , Diabetic Ketoacidosis/chemically induced , Intraoperative Complications/chemically induced , Postoperative Complications/chemically induced , Sodium-Glucose Transporter 2 Inhibitors/adverse effects , Diabetic Ketoacidosis/diagnosis , Humans , Intraoperative Complications/blood , Intraoperative Complications/diagnosis , Postoperative Complications/blood , Postoperative Complications/diagnosisABSTRACT
Arteriovenous malformation (AVM) is a rare vascular anomaly of the lung, which manifests predominantly as dyspnea (due to right to left shunting) and paradoxical embolism. Hereditary Hemorrhagic Telangiectasia (HHT) being a rare genetic disorder is one of the most common causes of pulmonary arteriovenous malformation (PAVM). Here we report an interesting case of recurrent anemia in an elderly female, who was subsequently found to have multiple cutaneous and mucosal telangiectasias and a large pulmonary AVM.