JA Clinical Reports最新文献

{"title":"Suspected anaphylaxis during anesthesia induction without identified allergens: a case report","authors":"Sayaka Hirai, Mitsuru Ida, Ai Arima, Masahiko Kawaguchi","doi":"10.1186/s40981-023-00684-y","DOIUrl":"https://doi.org/10.1186/s40981-023-00684-y","url":null,"abstract":"<p>To the Editor,</p><p>The Japanese Society of Anesthesiologists offers practical guidelines for dealing with perioperative anaphylaxis, emphasizing the importance of anesthesiologists’ involvement in identifying the causative agent to prevent recurrence [1]. However, identifying the causative agents is not always feasible. Herein, we report, with written informed consent, a case where anaphylaxis was suspected during anesthesia induction, yet no allergens were identified.</p><p>A 59-year-old man, 165.5 cm in height and weighing 65.1 kg, presented with congestive heart failure, chronic kidney disease, diabetes, hypertension, and hyperlipidemia, requiring coronary artery bypass grafting for triple-vessel coronary artery disease. The patient had not undergone any surgery previously and had not taken any angiotensin receptor blockers and angiotensin-converting enzyme inhibitors. In the operating room, standard vital signs were closely monitored, and non-invasive blood pressure (NIBP) was recorded at 160/120 mmHg. Anesthesia was induced using remifentanil (rate, 20 mL/h) and remimazolam (12 mg/kg/h). Upon confirming the loss of consciousness, the dosages of remifentanil and remimazolam were reduced to 5 mL/h and 1.0 mg/kg/h, respectively, four minutes after administering rocuronium (60 mg). This was followed by tracheal intubation and arterial catheter insertion. His blood pressure (BP) was 89/67 mm Hg (NIBP) and 47/25 mm Hg (arterial line) immediately before and after tracheal intubation, respectively. Despite fluid resuscitation of 500 mL and multiple boluses of ephedrine (16 mg), phenylephrine (0.3 mg), and norepinephrine (10 µg), he experienced cardiac arrest. During chest compressions, an intravenous bolus of epinephrine (0.1 mg) was administered, resulting in cardiopulmonary resuscitation with an arterial BP of 46/29 mmHg. However, due to persistent severe hypotension, continuous infusions of norepinephrine at 0.1 mcg/kg/min and dobutamine at 5 mcg/kg/min were initiated following additional boluses of epinephrine (0.3 mg). Figure 1 displays the patient’s vital signs during anesthesia. Edema with erythema of the extremities and trunk was observed throughout this sequence, and transesophageal echocardiography revealed no evidence of cardiogenic shock. Consequently, anaphylaxis was suspected, and the patient was transferred to the intensive care unit without proceeding with surgery. Blood samples taken before he left the operating room indicated an elevated serum tryptase level of 17.1 μg/L, exceeding the normal range of 1.2–5.7 μg/L. More than seven weeks after the onset, both basophil activation and skin prick tests using remimazolam and rocuronium yielded negative results. The patient declined surgery and was subsequently followed-up after percutaneous coronary intervention at coronary segments 6, 7, 11, and 14.</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 1</b></figcaption><picture><img alt=\"figure 1\" aria-describedby=\"Fig1\"","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":null,"pages":null},"PeriodicalIF":0.9,"publicationDate":"2023-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138714628","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}