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 Table of Contents  
LETTER TO EDITOR
Year : 2019  |  Volume : 21  |  Issue : 2  |  Page : 201-203

Anaphylaxis in nonoperating room anaesthesia: Bizarre complication


1 Department of Anaesthesiology and Critical Care, AFMC, Pune, Maharastra, India
2 Department of Obstetrics and Gynaecology, INHS, Asvini, Mumbai, Maharastra, India

Date of Web Publication07-Oct-2019

Correspondence Address:
Lt Col (Dr) Debashish Paul
Department of Anaesthesiology and Critical Care, AFMC, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_44_18

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How to cite this article:
Patnaik S, Sharma R, Paul D, Khan S. Anaphylaxis in nonoperating room anaesthesia: Bizarre complication. J Mar Med Soc 2019;21:201-3

How to cite this URL:
Patnaik S, Sharma R, Paul D, Khan S. Anaphylaxis in nonoperating room anaesthesia: Bizarre complication. J Mar Med Soc [serial online] 2019 [cited 2019 Oct 17];21:201-3. Available from: http://www.marinemedicalsociety.in/text.asp?2019/21/2/201/268624



Sir

Reported perianesthesia anaphylaxis is rare, especially in the developing countries, where database records are poorly maintained. Reported cases have shown incidences approximately ranging from 1 in 3500 to 1 in 25,000.[1],[2] Anaphylaxis is a lethal, acute condition involving multiple systems due to release of mediators derived from mast cell and basophiles.[3] There are remote locations or non operating rooms where anaesthesiologists are required to administer anaesthesia or sedations like radiological suites, endoscopy suites, psychiatric units, gynaecology units for in vitro fertilizations. It is a challenging task to the anesthesiologist with respect to the equipment, staff, procedure, and the patient. Serious anaphylactic reactions during anesthesia and in the perioperative period in such locations, if not recognized and managed promptly can rapidly evolve into life-threatening situations. Under reporting of such cases has led to lack of awareness about the magnitude of the problem. Here, we are reporting a case report of anaphylaxis most likely to tranexamic acid (TXA) during perioperative period in a patient in one of the gynecology units (assisted reproductive center) of a tertiary care center.


  Case Report Top


A 26-year-old female (height: 162 cm and weight: 56 kg), a case of primary infertility planned for ovum pick up under general anesthesia at assisted reproductive technology (ART) center of a tertiary care hospital. The history suggested no drug or food allergies; nothing significant was there to report in preoperative examinations – clinical findings and investigations. The patient was accepted under the American Society Association (ASA) Physical Status Classification 1.

The patient received no premedication before being shifted to the operating table. The initial vitals of the patient were as follows: heart rate (HR) of 80 beats/min and blood pressure (BP) of 132/86 mmHg with oxygen saturation (SpO2) of 99% in room air. Premedication was done with injection glycopyrrolate 0.2 mg intravenous (IV), injection midazolam 2 mg IV, injection ondansetron 4 mg, and injection fentanyl 100 mcg IV. Induction was done with injection ketamine 15 mg and injection propofol 100 mg IV, and maintenance of anesthesia was achieved by oxygen (50%), nitrous oxide (50%), and sevoflurane (1%–2%) by the face mask. Intraoperative vitals were stable. Total IV fluid of 500 ml of Ringer's lactate was administered. Her recovery was complete, spontaneous, and uneventful. In the postoperative area, the patient was kept under observation with all ASA standard monitors. 1 g of TXA in 500 ml of Ringer's lactate was started slowly. After approximately 15 min, the patient started complaining of breathlessness and difficulty in breathing. On examination, she was restless, anxious, shivering, and hyperventilating. HR was 110–130 beats/min, SpO2 dropped till 88%–84%, and BP recorded was 84/46 mmHg. On auscultation of chest, expiratory wheeze was present. Clinical features were suggestive of anaphylaxis or adverse drug reaction.

The patient was resuscitated immediately. IV fluids with TXA were stopped and changed to normal saline (0.9%). Injection hydrocortisone 200 mg IV, injection pheniramine maleate 25 mg IV stat, and injection adrenaline 1 mg IV were administered. The patient remained to be hypotensive (mean arterial pressure <45 mmHg) and vasopressor support with injection noradrenaline infusion was started @0.02–0.1 mcg/kg/min by titration. In view of persistent hypotension, tachycardia, and deteriorating SpO2, the patient was intubated and shifted to the intensive care unit (ICU) for close hemodynamic monitoring and ventilator support.

In the ICU, the patient gradually improved. By the next day morning, sedation and noradrenaline support was completely tapered off. She was extubated and subsequently discharged from the ICU. Blood samples were obtained for the serum tryptase level, serum histamine level, and total immunoglobulin E (IgE) level followed by planned skin prick test after 6 weeks.


  Discussion Top


Anaphylaxis is highly suspected when one of the following three criteria is fulfilled. The criteria are as follows: (1) acute onset of illness with skin involvement and either respiratory compromise or a systolic BP <90 mmHg; (2) two or more signs or symptoms of an allergic reaction occurring rapidly following exposure to a likely allergen; and (3) systolic BP <90 mmHg or symptomatic hypotension following exposure to the allergen. In the present case, two criteria were present.[4]

TXA is an antifibrinolytic drug used in the prevention and treatment of excessive bleeding during the perioperative period. Although anaphylaxis during anesthesia is most frequently caused by allergy to the neuromuscular blocking agents followed by antibiotics and opiate,[5] this case reports an unusual event where TXA is the offending agent. Serum histamine levels were 153 nmol/L, suggestive of an allergic reaction. Our patient had several similarities as compared to other case report on TXA anaphylaxis.[6] Serum tryptase level was within normal limits (borderline), as samples were taken almost 4 h after the event. Ideally, the sample should have been sent for laboratory investigation within first hour of the incident. We tried to get a TXA-specific IgE, but the report was inconclusive. Type 1 hypersensitivity appears to be the most frequent manifestation of TXA allergy which is IgE mediated.[7]

Anaphylaxis is a clinical diagnosis. Investigations of such cases are challenging, as a number of drugs are given in a short span of time.[8] It requires an accurate record of events during anesthesia. Laboratory tests are not useful in diagnosing anaphylaxis at the time of presentation because they are time-consuming and are prone for wrong result. A small quantity of allergen is sufficient to stimulate immune cells and causes anaphylaxis. Not considering the cause, an elevation followed by decline to normal levels of the serum mast cell tryptase, histamine is enormously helpful to confirm mast cell degranulation. Interpretation of serum tryptase levels, percentage change from baseline, and absolute tryptase measurement in the acute phase help in identifying IgE-mediated anaphylaxis.[9] The underlying mechanism is of no significance while making clinical diagnosis and management of anaphylaxis. However, by identification of the allergen, it is possible to avoid allergic anaphylaxis during subsequent anesthesia.[10] Adrenaline remains the most effective first-line intervention in management.

Till date, only two cases with a detailed report of anaphylaxis with TXA are available.[6],[11] There is some retrospective analysis where systemic reactions have been reported after oral or parenteral administration of TXA.[12] In most of cases, skin testing and blood tests were not performed to confirm allergy to TXA. In the present case, the patient underwent skin prick test for the antibiotic used (ceftriaxone), propofol, opioids, and TXA. Ringer's lactate was excluded from the list of suspected agent, as the patient was exposed to the same in the ward and ART center previously. Skin test showed nonspecific reactions and moderately positive wheal test for TXA with complete negative tests for other drugs. Intradermal testing was not significant with any of the drug. On the basis of these results, we assumed that TXA is the probable cause of the allergic reaction. The same patient had to come for embryo reduction where the same set of drugs being used minus TXA. Everything underwent well without any untoward incident.


  Conclusion Top


Anaphylactic reactions can happen due to any of the common drugs in the perioperative period. Anesthesiologists should always be aware and prepared for the possibility of anaphylactic reactions to all drugs used during anesthetic management even at remote locations. The beginning of antagonistic therapy is essential when anaphylaxis is strongly suspected, and tests to determine the specific drug responsible should be conducted immediately to prevent further adverse events.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: Systematic review and cumulative meta-analysis. BMJ 2012;344:e3054.  Back to cited text no. 1
    
2.
Sampson HA, Muñoz-Furlong A, Bock SA, Schmitt C, Bass R, Chowdhury BA, et al. Symposium on the definition and management of anaphylaxis: Summary report. J Allergy Clin Immunol 2005;115:584-91.  Back to cited text no. 2
    
3.
Muraro A, Roberts G, Worm M, Bilò MB, Brockow K, Fernández Rivas M, et al. Anaphylaxis: Guidelines from the European academy of allergy and clinical immunology. Allergy 2014;69:1026-45.  Back to cited text no. 3
    
4.
Simons FE, Ebisawa M, Sanchez-Borges M, Thong BY, Worm M, Tanno LK, et al. 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines. World Allergy Organ J 2015;8:32.  Back to cited text no. 4
    
5.
Hepner DL, Castells MC. Anaphylaxis during the perioperative period. Anesth Analg 2003;97:1381-95.  Back to cited text no. 5
    
6.
Lucas-Polomeni MM, Delaval Y, Menestret P, Delaval P, Ecoffey C. A case of anaphylactic shock with tranexamique acid (Exacyl). Ann Fr Anesth Reanim 2004;23:607-9.  Back to cited text no. 6
    
7.
Kavanagh GM, Sansom JE, Harrison P, Warwick JA, Peachey RD. Tranexamic acid (Cyklokapron)-induced fixed-drug eruption. Br J Dermatol 1993;128:229-30.  Back to cited text no. 7
    
8.
Ewan PW, Dugué P, Mirakian R, Dixon TA, Harper JN, Nasser SM, et al. BSACI guidelines for the investigation of suspected anaphylaxis during general anaesthesia. Clin Exp Allergy 2010;40:15-31.  Back to cited text no. 8
    
9.
Krishna MT, York M, Chin T, Gnanakumaran G, Heslegrave J, Derbridge C, et al. Multi-centre retrospective analysis of anaphylaxis during general anaesthesia in the United Kingdom: Aetiology and diagnostic performance of acute serum tryptase. Clin Exp Immunol 2014;178:399-404.  Back to cited text no. 9
    
10.
Trautmann A, Seidl C, Stoevesandt J, Seitz CS. General anaesthesia-induced anaphylaxis: Impact of allergy testing on subsequent anaesthesia. Clin Exp Allergy 2016;46:125-32.  Back to cited text no. 10
    
11.
Bansal RA, Nicholas A, Bansal AS. Tranexamic acid: An exceedingly rare cause of anaphylaxis during anaesthesia. Case Reports Immunol 2016;2016:7828351.  Back to cited text no. 11
    
12.
Imbesi S, Nettis E, Minciullo PL, Di Leo E, Saija A, Vacca A, et al. Hypersensitivity to tranexamic acid: A wide spectrum of adverse reactions. Pharm World Sci 2010;32:416-9.  Back to cited text no. 12
    




 

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