RESUMO
BACKGROUND: Diagnosing perioperative anaphylaxis (POA) is often challenging. Although a guideline recommends measuring tryptase rather than histamine, there is little evidence for this. We aimed to examine the diagnostic performance and appropriate timing of tryptase and histamine measurements for diagnosing anaphylaxis, and the association between Hypersensitivity Clinical Scoring Scheme (HCSS) scores and elevated biomarkers. METHODS: We measured tryptase and histamine levels thrice: 30 min, 2 h, and at least 24 h after an anaphylactic event for patients with suspected anaphylaxis, and at the induction of general anesthesia and 30 min and 2 h after the start of surgery for control patients without a reaction. Absolute values and the magnitude and rate of change from baseline were evaluated. We determined the thresholds of tryptase and histamine levels with the best diagnostic performance and compared their performance. RESULTS: Forty-five patients with perioperative anaphylaxis were included in this study. The control group included 30 patients with uneventful general anesthesia and 12 patients with a suspected but unconfirmed diagnosis of perioperative anaphylaxis. Comparison at the same measurement timings showed that tryptase generally had better diagnostic performance than histamine. Both showed better diagnostic performance when assessed using multiple measurements rather than a single measurement. The best diagnostic performance was seen with the percentage change in the higher tryptase value, whether measured at 30 min or 2 h after anaphylaxis onset, as compared to baseline. However, neither tryptase nor histamine levels correlated with HCSS scores. CONCLUSIONS: Overall, tryptase showed better diagnostic performance than histamine. When multiple tryptase measurements are possible, parameters calculated using two acute phase measurements and the baseline level have better diagnostic performance.
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BACKGROUND: There are no effective pharmacologic interventions for preventing postoperative cognitive dysfunction in daily practice. Since the antibiotic minocycline is known to suppress postoperative neuroinflammation, this study hypothesized and investigated whether minocycline might have a preventive effect on postoperative cognitive dysfunction after noncardiac surgery. METHODS: This study included patients aged more than 60 yr undergoing total knee arthroplasty under general anesthesia. They were randomly assigned to minocycline and placebo groups, to orally receive 100 mg of minocycline or placebo twice daily from the day before surgery until the seventh day after surgery. Cognitive function was evaluated before surgery, and 1 week and 3 months after surgery, using a battery of four cognitive function tests, including Visual Verbal Learning Test, Trail Making Test, Stroop Color and Word Test, and Letter-Digit Coding Task. Additionally, 30 healthy volunteers were subjected to the same tests as the patients to examine the learning effect of repeated tests. The occurrence of postoperative cognitive dysfunction was judged from the results of the neurocognitive test battery, with consideration of the learning effect. The secondary endpoints were the effects of minocycline on postoperative delirium and postoperative pain. RESULTS: A total of 100 patients were randomized to the minocycline group, and 102 were randomized to the placebo group. The average age of patients was 75 yr. Evaluation showed no significant difference in the incidence of postoperative cognitive dysfunction between the minocycline and placebo groups at both 1 week (8 of 90 [8.9%] vs. 4 of 95 [4.2%]; odds ratio, 2.22 [95% CI, 0.64 to 7.65]; P = 0.240) and 3 months (15.3 of 90 [17.0%] vs. 15.3 of 95 [16.1%]; odds ratio, 1.07 [95% CI, 0.49 to 2.32]; P = 0.889) postoperatively. Missing data 3 months after surgery were corrected by the multiple imputation method. There were no differences between the two groups in postoperative delirium and postoperative pain. CONCLUSIONS: Minocycline is likely to have no preventive effect on postoperative cognitive dysfunction.
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Artroplastia do Joelho , Disfunção Cognitiva , Delírio do Despertar , Complicações Cognitivas Pós-Operatórias , Idoso , Humanos , Minociclina/uso terapêutico , Complicações Cognitivas Pós-Operatórias/prevenção & controle , Artroplastia do Joelho/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Método Duplo-Cego , Disfunção Cognitiva/prevenção & controle , Disfunção Cognitiva/epidemiologiaRESUMO
BACKGROUND: Diagnosis of perioperative anaphylaxis is difficult because of its non-specific and variable signs and symptoms. Therapeutic agents used to treat anaphylaxis and anaesthesiologist responses also vary depending on the case, which might affect outcomes; however, only a few studies have focused on these factors. METHODS: This prospective study of perioperative anaphylaxis, a part of the Japanese Epidemiologic Study for Perioperative Anaphylaxis, investigated the clinical signs, its severity, therapeutic drugs, epinephrine administration, and anaesthesiologist responses in cases of perioperative anaphylaxis to assess trends and variability. Shock index was used to assess severity of cardiovascular collapse. RESULTS: In 43 patients analysed in this study, cardiovascular signs (88.4%) were the most frequent, followed by skin (81.4%) and respiratory signs (60.5%). The presence of signs increased during the clinical course. The median time from the first signs to diagnosis of anaphylaxis was 10 (5.0-17.8) min. The rates of epinephrine use were 30.2% (unused), 48.8% (i.v.), and 20.9% (i.m.). The median time from diagnosis of anaphylaxis to epinephrine administration was 7 (inter-quartile range: 1.5-8.0) min. Antihistamines and corticosteroids were each used in 69.8% of cases. The worst shock index was higher in patients who received i.v. epinephrine (2.77 [0.90] mean [standard deviation]) than in both no epinephrine use cases (1.35 [0.41]) and i.m. epinephrine cases (1.89 [0.77] (P<0.001]). CONCLUSIONS: The clinical signs and treatments of perioperative anaphylaxis are variable, and the choice regarding epinephrine administration is based on symptom severity. CLINICAL TRIAL REGISTRATION: UMIN000035350.
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Anafilaxia , Anestesia , Humanos , Corticosteroides/uso terapêutico , Anafilaxia/diagnóstico , Anafilaxia/tratamento farmacológico , Anafilaxia/epidemiologia , População do Leste Asiático , Epinefrina/uso terapêutico , Estudos Prospectivos , Anestesia/efeitos adversosRESUMO
BACKGROUND: Diagnosis of perioperative anaphylaxis is often challenging. This study describes the utility of a newly developed tool for identifying patients with a high possibility of anaphylaxis, and aimed to investigate the frequency of anaphylaxis with each drug during the perioperative period in Japan. METHODS: This study included patients with anaphylaxis of Grade 2 or higher severity during general anaesthesia at 42 facilities across Japan in 2019 and 2020. We developed and adopted a unique objective evaluation tool yielding a composite score for diagnosing anaphylaxis, which includes the results of skin tests and basophil activation tests, and clinical scores for perioperative anaphylaxis. The number of cases using each drug and the total number of anaphylaxis cases were investigated to calculate the frequency of anaphylaxis. RESULTS: General anaesthesia was performed in 218 936 cases, which included 55 patients with suspected perioperative anaphylaxis. The developed composite score diagnosed 43 of them with a high probability of anaphylaxis. The causative agent was identified in 32 cases. Plasma histamine levels showed high diagnostic accuracy for anaphylaxis. The top causative agents were rocuronium (10 cases in 210 852 patients, 0.005%), sugammadex (7 cases in 150 629 patients, 0.005%), and cefazolin (7 cases in 106 005 patients, 0.007%). CONCLUSIONS: We developed a composite tool to diagnose anaphylaxis, and found that the combination of tryptase levels, skin testing, and basophil activation testing results and clinical score improved the certainty of anaphylaxis diagnosis. The incidence of perioperative anaphylaxis in our study was 1 in about 5000 general anaesthesia cases. CLINICAL TRIAL REGISTRATION: UMIN000035350.
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Anafilaxia , Hipersensibilidade a Drogas , Humanos , Anafilaxia/diagnóstico , Anafilaxia/epidemiologia , Estudos Prospectivos , População do Leste Asiático , Anestesia Geral/efeitos adversos , Alérgenos , Hipersensibilidade a Drogas/diagnóstico , Hipersensibilidade a Drogas/epidemiologiaRESUMO
Although several guidelines recommend measuring blood tryptase and histamine concentrations to diagnose perioperative anaphylaxis (POA), tryptase measurement is more common. The appropriate timing of blood collection and the diagnostic threshold for histamine measurement are still controversial. To address these issues, histamine concentrations in patients with anaphylaxis and those with anaphylaxis-uncertain were compared in our previous study, the Japanese Epidemiologic Study for Perioperative Anaphylaxis (JESPA). However, because we could not rule out the possibility that the anaphylactic-uncertain group included anaphylactic patients, histamine concentrations were measured in patients who underwent general anesthesia with no complications as controls in the present study. Histamine levels were measured at anesthesia induction (baseline), 30 min (first point), and 2 h (second point) after the start of surgery in 30 control patients. Histamine concentrations in controls were lower than in patients with POA in JESPA at the first and second points. At the first point, a threshold of 1.5 ng/ml resulted in sensitivity of 77% and specificity of 100%. A threshold of 1.1 ng/ml at the second point resulted in sensitivity of 67% and specificity of 87%. Measurement of histamine concentrations within two hours after symptom onset might help diagnose POA.
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Anafilaxia , Histamina , Humanos , Anafilaxia/diagnóstico , Triptases , Estudos Prospectivos , Anestesia Geral/efeitos adversosRESUMO
Since perioperative anaphylaxis occurs suddenly, and it can be life-threatening, anesthesiologists need to have sufficient knowledge of the epidemiology of perioperative anaphylaxis and appropriate coping strategies to deal with it. Recent studies conducted in Western countries reported the characteristics of perioperative anaphylaxis in each country. However, there are few studies of perioperative anaphylaxis in Japan. To bridge the gap between Japan and other countries, the data of 46 anaphylaxis patients at Gunma University Hospital and 13 neighboring hospitals between 2012 and 2018 were collected and analyzed. The recently developed clinical scoring system was combined with a skin test to include only cases with a definite diagnosis. The most common causative agents were sugammadex, followed by rocuronium, cefazolin, and antibiotics other than cefazolin. Furthermore, the characteristics of anaphylaxis for each causative drug were identified. Time from drug administration to appearance of the first symptom was the longest in the cefazolin group. The incidence of canceled operation was the highest in the rocuronium group. Although it is unclear whether the results of this study can apply to Japan as a whole, the information about the agents responsible for perioperative anaphylaxis and the characteristics of anaphylaxis due to each agent would be helpful to anesthesiologists.
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Anafilaxia , Preparações Farmacêuticas , Anafilaxia/induzido quimicamente , Anafilaxia/epidemiologia , Anestesia Geral/efeitos adversos , Humanos , Japão/epidemiologia , Estudos Retrospectivos , Centros de Atenção TerciáriaRESUMO
BACKGROUND: Although cases of anaphylaxis caused by sugammadex have been reported, its incidence remains uncertain. Conversely, no studies have evaluated the incidence of anaphylaxis to neostigmine. METHODS: This was a retrospective multicentre observational study of patients who underwent surgery under general anaesthesia between 2012 and 2016 to compare the incidence of anaphylaxis with sugammadex with that of neostigmine at four tertiary hospitals in Japan. To ensure the quality of diagnosis, only cases with a clinical history suggestive of anaphylaxis, along with positive results from in vitro or in vivo testing, were assessed. RESULTS: From a total of 49 532 patients who received general anaesthesia included in this study, 18 cases of anaphylaxis were reported, of which six were attributable to sugammadex and none to neostigmine. There were no fatalities attributable to anaphylaxis. The incidence of anaphylaxis caused by all drugs or by sugammadex was calculated as 0.036% (95% confidence interval [CI]: 0.022-0.057%) and 0.02% (of the number of sugammadex cases) (95% CI: 0.007-0.044%), respectively. CONCLUSIONS: The results suggest that neostigmine might be safer than sugammadex when assessing only the incidence of anaphylaxis. We believe that there is room for reconsideration of the choice of reversal agent for neuromuscular blocking agents by all anaesthetists. CLINICAL TRIAL REGISTRATION: UMIN000022365; UMIN000033561.
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Anafilaxia/induzido quimicamente , Inibidores da Colinesterase/efeitos adversos , Neostigmina/efeitos adversos , Sugammadex/efeitos adversos , Adolescente , Adulto , Idoso , Feminino , Humanos , Incidência , Japão , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
Skin tests are the gold standard for detecting the culprit drug of anaphylaxis, and should ideally be performed after an interval of 4-6 weeks after the reaction to avoid false-negative results. However, when re-operation cannot be delayed and early allergy tests are necessary, special attention is required during subsequent anesthesia, because early skin tests tend to produce false-negative results. This report presents a case of rocuronium-induced anaphylaxis in which early skin tests showed negative results for all the drugs tested. The second anesthesia was safely performed by avoiding all the drugs used for the first anesthesia. Ultimately, skin tests and basophil activation tests (BATs) performed after re-operation demonstrated rocuronium as the drug responsible for anaphylaxis. We recommend performing BATs in addition to skin tests to improve the accuracy of diagnosis of anaphylaxis. In this report, we also discuss interpretation of the results of early skin tests and subsequent selection of drugs for anesthesia. After postponement of surgery due to anaphylaxis, we are often required to perform allergy tests at an early stage if re-operation cannot be delayed. In such cases, skin test results alone should not be used to guide subsequent anesthesia management to avoid recurrent anaphylaxis.
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Anafilaxia , Anestesiologia , Adulto , Idoso , Anafilaxia/diagnóstico , Anafilaxia/etiologia , Anestesia Geral , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Rocurônio , Testes CutâneosRESUMO
BACKGROUND: Sugammadex is used to reverse the effects of neuromuscular blocking agents in many cases of general anesthesia. However, there are several reports of anaphylaxis after its use. Skin testing is the gold standard for detecting the causative agent of anaphylaxis. However, due to the lack of validated protocols for skin testing with sugammadex, the diagnostic accuracy might be inadequate. Recently, the basophil activation test (BAT) has been established as a tool to detect the causative agent of anaphylaxis with high sensitivity and specificity. However, few studies have investigated the utility of the BAT for sugammadex-induced anaphylaxis. METHODS: Eight patients who presented with immediate hypersensitivity to sugammadex during general anesthesia were included in this study. We conducted skin tests to confirm the diagnosis of sugammadex-induced anaphylaxis. Twenty-one sugammadex-naive individuals who had a negative skin test for allergy to this drug were enrolled as controls. Basophils were selected on a CD3/CRTH2 gate and labeled with CD63 and CD203c. RESULTS: The ratios of activated basophils in the patients were much higher than those in controls: the median values of areas under the curves in the patients and controls for CD203c were 1,265,985 (95% confidence interval [CI], 77,580-5,040,270) and 116,325 (95% CI, -268,605 to 232,690), respectively (Mann-Whitney U test, P < .01), and the areas under the curves in the patients and controls for CD63 were 788,647 (95% CI, 120,285-3,523,410) and 220,005 (95% CI, -50,346 to 404,680), respectively (Mann-Whitney U test, P < .01). The patients, but not controls, demonstrated clear dose-dependent CD203c upregulation. This was also true for CD63. In the case of CD203c, the sensitivity of the BAT for sugammadex was 88% (95% CI, 47%-100%), and specificity was 100% (95% CI, 84%-100%), while sensitivity and specificity for CD63 were 75% (95% CI, 35%-97%) and 100% (95% CI, 84%-100%), respectively. CONCLUSIONS: The BAT seems to have comparable accuracy to skin tests for the diagnosis of sugammadex-induced anaphylaxis. For this purpose, both CD203c and CD63 can be used to detect activated basophils.
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Anafilaxia/sangue , Anafilaxia/diagnóstico , Basófilos/efeitos dos fármacos , Basófilos/metabolismo , Sugammadex/efeitos adversos , Adolescente , Adulto , Idoso , Anafilaxia/induzido quimicamente , Hipersensibilidade a Drogas/sangue , Hipersensibilidade a Drogas/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueadores Neuromusculares/efeitos adversos , Estudos Prospectivos , Testes Cutâneos/métodosRESUMO
PURPOSE: Identifying the causative agent of perioperative anaphylaxis is key to preventing its recurrence. Besides skin testing, the basophil activation test (BAT) is increasingly being accepted as an additional and reliable method. Cefazolin seems to be a major cause of perioperative anaphylaxis. However, few studies have described use of the BAT for cefazolin-induced anaphylaxis. In this study, we aimed to determine the optimum cefazolin concentration required in the BAT for an accurate diagnosis. METHODS: Seven patients who presented with immediate hypersensitivity to cefazolin and 21 control subjects were studied. We conducted skin tests and performed BATs using both CD203c and CD63 as markers of activated basophils. We measured the ratio of activated basophils after stimulation with serial dilutions of cefazolin and investigated the cefazolin concentration that resulted in better sensitivity and specificity. RESULTS: All patients demonstrated positive reactions to cefazolin, while all control subjects showed negative reactions on skin tests. The net percentage of both CD203c- and CD63-labeled activated basophils was greater when higher concentrations of cefazolin than previously reported were used. In control subjects, however, the number of activated basophils by cefazolin stimulation was negligible regardless of its concentration. In the case of CD203c, the sensitivity was 86% with a cefazolin concentration of 3 mg/ml, while in the case of CD63, the sensitivity was 100% with a cefazolin concentration of 10 mg/ml. CONCLUSION: Using a higher concentration of cefazolin than previously reported for the BAT might increase the accuracy of diagnosis of cefazolin-induced anaphylaxis.
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Anafilaxia/induzido quimicamente , Basófilos/imunologia , Cefazolina/administração & dosagem , Adolescente , Adulto , Idoso , Biomarcadores/metabolismo , Cefazolina/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Diester Fosfórico Hidrolases/metabolismo , Estudos Prospectivos , Pirofosfatases/metabolismo , Sensibilidade e EspecificidadeRESUMO
We experienced rocuronium-induced anaphylaxis in a 62-year-old man who was scheduled for laparoscopic ileocecal excision for cecal cancer under general anes- thesia. The patient did not have a preoperative history and examinations suggestive of heart disease, or pre- disposing factors for myocardial infarction. Just after induction of anesthesia, we noticed abnormally low blood pressure and ST segment elevation on his elec- trocardiogram. The surgery was postponed and percu- taneous coronary intervention was performed to treat coronary artery stenosis. Re-operation was planned 73-days after the first operation. The patient suffered cardiac arrest just after induction of general anesthesia At the same time, we noticed systemic erythema all over his body, which led to the diagnosis of anaphy- laxis. Cardiopulmonary resuscitation was performed and the surgery was postponed once again. Cardiovas- cular agents, including adrenaline, noradrenaline, atro- pine and amiodarone, improved his hemodynamics. In addition, steroids and anti-histamines were also admin- istered to treat anaphylaxis. We advised him to undergo skin tests to determine the causative agent of anaphylaxis, but he declined. Instead, a basophil activa- tion test was performed, which showed a positive reac- tion to rocuronium. Therefore, we planned general anesthesia without using muscle relaxants such as rocuronium for the third attempt at surgery. The sur- gery was performed safely with this protocol. It is likely that his symptoms in the first general anesthesia were caused by Kounis syndrome. We conclude that the basophil activation test seems to be valuable in determining the causative agent of anaphylaxis, partic- ularly when a patient does not agree to undergo skin tests.
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Anafilaxia/induzido quimicamente , Basófilos/efeitos dos fármacos , Síndrome de Kounis , Rocurônio/efeitos adversos , Anestesia Geral , Neoplasias do Apêndice/cirurgia , Humanos , Masculino , Pessoa de Meia-IdadeAssuntos
Hipersensibilidade a Drogas/imunologia , Imunoglobulina E/imunologia , Proteínas do Tecido Nervoso/imunologia , Fármacos Neuromusculares não Despolarizantes/efeitos adversos , Receptores Acoplados a Proteínas G/imunologia , Receptores de Neuropeptídeos/imunologia , Rocurônio/efeitos adversos , Adolescente , Adulto , Idoso , Feminino , Humanos , Imunoglobulina E/efeitos dos fármacos , Masculino , Pessoa de Meia-Idade , Fármacos Neuromusculares não Despolarizantes/imunologia , Estudos Retrospectivos , Rocurônio/imunologia , Testes Cutâneos , Adulto JovemRESUMO
Intraocular pressure (IOP) has been shown to change with body position. Several studies have shown that the lateral decubitus position (LDP) is associated with a significant increase in IOP in the dependent eye. However, whether anesthetic agents alter IOP in the LDP remains unclear. This study investigated the effect of sevoflurane and propofol anesthesia on IOP in the LDP. A total of 28 patients undergoing surgery in the LDP were included. Patients were randomly allocated to sevoflurane or propofol groups. IOP in both eyes was recorded and compared between groups at five time points: after anesthesia induction, after endotracheal intubation, at 5 min and 1 h after a positional change to the LDP, and 5 min after returning to the supine position. In the sevoflurane group, IOP was significantly increased in both dependent and non-dependent eyes 1 h after changing to the LDP. In the propofol group, IOP decreased in both dependent and non-dependent eyes after tracheal intubation, but did not increase after changing to the LDP. The number of patients in whom IOP increased to ≥28 mmHg was greater in the sevoflurane group than in the propofol group. Propofol may be better than sevoflurane for the maintenance of anesthesia in the LDP. Monitoring of IOP in the LDP might help avoid ophthalmic complications.
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Anestesiologia/métodos , Anestésicos/administração & dosagem , Pressão Intraocular/fisiologia , Éteres Metílicos/administração & dosagem , Propofol/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Anestesia/métodos , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Posicionamento do Paciente , Postura , Sevoflurano , Fatores de Tempo , Tonometria OcularRESUMO
We report here a case of rocuronium-induced anaphylactic shock in a 41-year-old woman. She was scheduled for partial hepatectomy due to liver metastasis of a pheochromocytoma. Anesthesia was induced with propofol, remifentanil, and rocuronium. Bag-mask ventilation was difficult, and her blood pressure fell to around 40 mmHg just after induction. Subsequently, her trachea was intubated and adrenaline was injected. However, due to the subsequent persistence of severe hypotension and hypoxia, cardiopulmonary resuscitation was necessary. Suspecting the development of pulmonary embolism or anaphylaxis, we performed transesophageal echography; however, no evidence of right heart dilatation was observed, indicating a low possibility of pulmonary embolism. Although her general condition was stabilized, surgery was canceled. Blood tests showed high serum histamine and tryptase levels, suggesting an Ig-E mediated allergic reaction. A skin test performed five weeks after anesthesia suggested that she had suffered from rocuronium-induced anaphylaxis. A skin test also showed cross-reactivity between rocuronium and vecuronium. Therefore, we did not use any neuromuscular agent for the subsequent surgery, which was completed uneventfully. Determining the drug responsible for anaphylaxis helps to prevent recurrence of anaphylaxis.
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Anafilaxia/induzido quimicamente , Androstanóis/efeitos adversos , Anestesia Geral/efeitos adversos , Embolia Pulmonar/etiologia , Adulto , Feminino , Humanos , Recidiva Local de Neoplasia , Bloqueadores Neuromusculares , Piperidinas , Propofol/efeitos adversos , Remifentanil , Rocurônio , Testes Cutâneos , Triptases/sangueAssuntos
Hipersensibilidade a Drogas/sangue , Hipersensibilidade a Drogas/diagnóstico , Imunoglobulina E/sangue , Rocurônio/efeitos adversos , Rocurônio/sangue , Basófilos/efeitos dos fármacos , Humanos , Fármacos Neuromusculares não Despolarizantes/efeitos adversos , Fármacos Neuromusculares não Despolarizantes/sangue , Reprodutibilidade dos Testes , Estudos Retrospectivos , Testes Cutâneos/métodos , Testes Cutâneos/estatística & dados numéricosRESUMO
BACKGROUND: Sugammadex has a unique mechanism of action and is widely used because of its safety and efficacy. A few recent reports have described allergic reactions to clinical doses of sugammadex. We hereby describe another series of cases of possible anaphylaxis to sugammadex. CASE PRESENTATION: We present three suspected cases of sugammadex-induced anaphylactic shock, including a 13-year-old boy who underwent laparoscopic appendectomy, a 75-year-old woman who underwent left knee arthroplasty, and a 34-year-old man who underwent left pansinectomy for sinobronchitis. All three patients received general anesthesia with rocuronium and their tracheas were intubated. Shortly after injection of sugammadex for reversal of rocuronium, all of them experienced a decrease in blood pressure along with mucocutaneous erythema. In the most severe case, reintubation after extubation was required due to difficulty in manual ventilation. All patients recovered with anti-allergic therapy. On later investigation, all three patients had a positive skin reaction to sugammadex. CONCLUSION: Our results suggest that physicians using sugammadex should be aware of the possibility of sugammadex-induced anaphylaxis.
Assuntos
Anafilaxia/etiologia , gama-Ciclodextrinas/efeitos adversos , Adolescente , Adulto , Idoso , Androstanóis , Apendicectomia/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Hipersensibilidade a Drogas/complicações , Hipersensibilidade a Drogas/diagnóstico , Feminino , Humanos , Masculino , Fármacos Neuromusculares não Despolarizantes , Seios Paranasais/cirurgia , Rocurônio , SugammadexRESUMO
INTRODUCTION: Pregnancy in a woman with heart and chronic renal failure can lead to life-threatening complications for both mother and child. Although such cases are often delivered by cesarean section, few reports have described anesthesia methods. CASE PRESENTATION: We encountered a case in which cesarean section was performed using combined spinal and epidural anesthesia for a pregnant woman with chronic renal and heart failure. The 35-year-old Japanese woman had been undergoing hemodialysis for several years. Heart failure symptoms that appeared during pregnancy initially improved with treatments such as increasing hemodialysis, but recurred. She was admitted to the intensive care unit. The initial plan was to deliver the baby after a few weeks, but further progression of heart failure became a concern. After a clinical conference among staff, a cesarean section with combined spinal and epidural anesthesia was scheduled for 24 weeks, 0 days of gestation. The anticoagulant for dialysis was also changed from heparin to nafamostat in preparation for cesarean section. Monitoring was started with central venous and radial artery pressures before induction of anesthesia. Combined spinal and epidural anesthesia was induced and the cesarean section was completed without complications. Surgery was initiated under continuous administration of phenylephrine, which was intended to avoid hypotension due to anesthesia. The hemodynamic and respiratory status of the patient remained stable postoperatively. After the cesarean section, morphine was administered epidurally and the epidural catheter was removed. CONCLUSION: Cesarean section was safely performed for a pregnant woman with renal and heart failure using combined spinal and epidural anesthesia.
Assuntos
Anestesia Epidural , Anestesia Obstétrica , Raquianestesia , Cesárea , Insuficiência Cardíaca , Falência Renal Crônica , Humanos , Feminino , Gravidez , Adulto , Insuficiência Cardíaca/complicações , Anestesia Epidural/métodos , Falência Renal Crônica/terapia , Falência Renal Crônica/complicações , Raquianestesia/métodos , Anestesia Obstétrica/métodos , Diálise Renal , Complicações Cardiovasculares na Gravidez/cirurgia , Complicações na Gravidez/cirurgiaRESUMO
BACKGROUND: Although chlorhexidine allergy has been shown to be mediated by immunoglobulin (Ig) E, few reports investigated the mechanism of chlorhexidine-induced anaphylaxis using basophil activation tests (BATs). CASE PRESENTATION: A 79-year-old man underwent cholecystectomy under general anesthesia. Anaphylaxis was diagnosed based on the clinical symptoms and high serum tryptase and histamine levels. Skin tests showed positive results only for chlorhexidine. Subsequently, BATs demonstrated that the causative agent was likely chlorhexidine. The inhibitory effect of wortmannin, an inhibitor of phosphoinositide 3-kinase, on basophil activation suggested an IgE-dependent mechanism underlying chlorhexidine-induced anaphylaxis. An 89-year-old man underwent inguinal hernioplasty under general anesthesia. Anaphylaxis was diagnosed based on the clinical symptoms and high serum tryptase and histamine levels. Skin tests and BATs with wortmannin were performed, showing similar results to case 1. CONCLUSIONS: BATs suggested an IgE-dependent mechanism for chlorhexidine-induced anaphylaxis and might be useful for investigating the mechanisms underlying drug-induced anaphylaxis.
RESUMO
We examined the dose-related effects of landiolol on hemodynamics during emergence from anesthesia of elderly patients with uncontrolled hypertension. Thirty-three normotensive, 34 controlled hypertensive, and 31 uncontrolled hypertensive elderly patients were divided into three groups: control (saline infusion), 0.125 landiolol group, and 0.25 landiolol group. Landiolol or saline infusion was administered at 0.125 (0.125 landiolol group) or 0.25 (0.25 landiolol group) mg/kg/min for 1 min and thereafter decreased to 0.04 or 0.08 mg/kg/min, respectively, until extubation, under regular heart rate and blood pressure monitoring. In normotensive patients, the 0.125 mg/kg/min landiolol infusion was suitable for stabilization of systolic blood pressure and heart rate during tracheal extubation. Controlled hypertensive patients required a 0.25 mg/kg/min landiolol infusion for stabilization of systolic blood pressure and heart rate during tracheal extubation. In uncontrolled hypertensive patients the 0.25 mg/kg/min landiolol infusion could stabilize heart rate, but not systolic blood pressure. In conclusion, the adequacy of preoperative hypertensive control could affect landiolol infusion-induced hemodynamic stability during emergence of elderly patients from anesthesia.