Article Information

XiaYao¹, Jing Wang², Baichen Liu¹, Xiaoli Rong³, Baohua Wang^1?

¹Department of Anesthesiology, Affiliated Hospital of Changchun University of Traditional Chinese Medicine, 1478 Gong nong Road, Changchun, Jilin 130033, China

²Gynecology, Affiliated Hospital of Changchun University of Traditional Chinese Medicine, 1478 Gong nong Road, Changchun, Jilin 130033, China

³The Scientific Research Center, China-Japan Union Hospital of Jilin University, 126 Xiantai St., Changchun, Jilin 130033, China

^*Corresponding Author: Dr. Baohua Wang, Department of Anesthesiology, Affiliated Hospital of Changchun University of Traditional Chinese Medicine, 1478 Gong nong Road, Changchun, Jilin 130033, China

Received: 19 June 2019; Accepted: 08 July 2019; Published: 16 September 2019

Citation: Xia Yao, Jing Wang, Baichen Liu, Xiaoli Rong, Baohua Wang. A Case Report of Anaphylactic Shock Induced by Cisatracurium. Archives of Clinical and Medical Case Reports 3 (2019): 285-288.

Share at Facebook

Abstract

Keywords

Anaphylactic shock, Cisatracurium, Case report

Article Details

1. Introduction

A variety of drugs will be used when patients undergoing general anesthesia within a short time, and various side effects may occur at the same time. However, allergic reactions are a life-threatening reaction. A recent study demonstrated that 90% of perioperative allergies occur during the anaesthesia induction period, 50% to 70% are caused by neuromuscular blockers, and succinylcholine and rocuronium are the most common, micuronium and cisatracurium are rare, the incidence of cisatracurium allergy is 1/1388 [1]. Although cisatracurium has a few histamine release, there several serious allergic reactions have been reported since clinical use [2-6]. Allergies are a rare side effect, but they can lead to death if not diagnosed timely and treated quickly. In addition, identifying allergens is the most important step to prevent relapse. Herein, we report a case of anaphylactic shock caused by cisatracurium under general anesthesia. This reminds anesthesiologists to be alert to allergic reactions during general anesthesia induction.

2. Case Report

The patient was 30 years old female, 60 kg weight, ASA grade I, diagnosed of cervical intraepithelial neoplasia, and prepared to undergo cervical conization under general anesthesia. She was in good health and had a history of penicillin allergy, no history of food allergy, all pre-operative examinations were normal. Routine preoperative fasting for 10 hours, monitoring in the operating room, blood pressure 120/70 mmHg, heart rate 70 beats/min, pulse oxygen saturation of 98%.

The patient arrived at the operating room with no premedication, anesthesia was induced by midazolam 1mg, fentanyl 0.2 mg, propofol 120 mg, and cisatracurium 5 mg. Then, the patient's oral secretions suddenly increased. We used the sputum suction tube to attract them, pulse oximetry decreasing to 85%, inserted larynx mask, poor ventilation, airway pressure increased to 28 cm H₂O. Blood pressure was70/35 mmHg, heart rate rose to 105 beats/min, gave ephedrine 10mg intravenously, blood pressure did not rise. Then, we gave the phenylephrine hydrochloride 100 μg intravenously, then, 10 mg was added to 100 ml saline intravenous drip. But, the blood pressure still did not rise and fell to 52/30 mmHg, heart rate was 120 beats/min, pulse oxygen saturation cannot be measured. We found conjunctival edema in the patient's eyes at this time, Therefore, we suspected that anaphylactic shock has occurred. So we took rescue measures immediately, gave 10 mg dexamethasone, injected 50 μg epinephrine intravenously, then1 mg epinephrine was added to 250 ml saline static point rapidly. After 3 minute, blood pressure rose to 80/42 mmHg, the heart rate was 110 beats/min. After 10 minutes, the blood pressure rose to 105/60 mmHg, heart rate was 90 beats/min, and airway pressure dropped to 20 cm H₂O, the condition of the patient improved. We adjust the speed of epinephrine drop, according to blood pressure.  After 20 minutes, the patient moved and opened the eyes and face became swelled. At this time, blood pressure was 110/68 mmHg, heart rate was 88 beats/min. After adrenaline decelerates, blood pressure drops, adrenaline need continues to static point. The patient's spontaneous breathing recovery, and pulled the laryngeal mask out. Her blood pressure was 115/67 mmHg, heart rate was 85 beats/min, pulse oxygen saturation was 98%. Then, she was transferred to ICU, the patient’s consciousness was clear, breathing was smooth, we saved the patient successfully.

After 6 weeks, the patient underwent the allergy testing. Skin test: midazolam, propofol, fentanyl, cisatracurium, rocuronium, lidocaine. Among them, cisatracurium  was positive (+) and the rest was negative (-). In order to avoid the use of cisatracurium, the operation was performed under epidural anesthesia with 1.8% lidocaine 20 ml. The anesthetic effect was well, no allergic reaction occurred during the operation. The operation went well and the patient returned to the ward safely. Follow-up the patients after surgery, there was nothing uncomfortable.

3. Discussion

Anaphylaxis is a severe, life-threatening, systemic hypersensitivity reaction. It is caused by the degranulation of mast cells or basophiles that results in the release of preformed mediators, including histamine and tryptase. These mediators can affect one or more organ systems such as the skin and the cardiovascular, respiratory, and gastrointestinal systems. The mechanisms that cause mast cell degranulation can be divided into immunemediated (IgE-mediated, anaphylactic) reactions and nonimmune-mediated (chemically-mediated, anaphylactic) reactions [7]. Isolated skin symptoms appear to be more common in non-IgE-mediated allergic reactions, while bronchial spasm and cardiovascular symptoms are more common in IgE-mediated allergic reactions [8]. In our case reported, the patient developed anaphylactic shock after induction of general anesthesia, no rash, but conjunctival edema and cardiovascular collapse. Drug skin tests showed that cisatracurium was positive, this could be diagnosed as immune-mediated IgE-mediated hypersensitivity according to clinical manifestations and skin tests. The retrospective diagnosis could depend on the results of serological and skin tests. Unfortunately, serological tests have not been performed in this case, but allergen specific IgE antibody tests (eg, radiosensitivity tests) are necessary, However, these tests are not yet available for cisatracurium in currently [9, 10].

Clinical use of muscle relaxant skin test as a predictor has few value, because a large number of false positive results can be produced in healthy people who have never used muscle relaxant. Therefore, muscle relaxant skin test is not recommended as a routine test before operation. However, the patients with a history of allergies to muscle relaxants, applied of non-diluted muscle relaxants for intradermal and acupuncture test has a high predictive value. However, this patient experienced a severe allergic reaction with the use of muscle relaxants firstly. This may be due to the fact that the patient had been exposed to some of the chemicals, such as detergents, disinfectants, and cosmetics which have the similar molecular characteristics to muscle relaxants. Quaternary ammonium groups are the common components, IgE antibodies produced by such antigens cross-react with muscle relaxants [11]. Due to the cross-sensitivity between muscle relaxants, and the severity of allergic reactions, we recommended the patient to avoid the use of muscle relaxants in subsequent anaesthesia, advocated regional or local anaesthesia. In this case, epidural anesthesia was used in the subsequent surgery and the anesthesia operation was successful.

In conclusion, during anesthesia induction, when the patient has a sharp drop in blood pressure, a sharp rise in heart rate, and an increase in respiratory resistance within an extremely short period, and no other reason can explain, it should be taken into account that there was a serious allergic event. The rescue measures should also get into the fast lane of anti-allergic shock as early as possible. It included that discontinuation of anesthetics or sensitizers, inhalation of pure oxygen, control of the airway, intravenous fluid rehydration rapidly, applied of glucocorticoids, the use of epinephrine early, and dare to use epinephrine. epinephrine is an alpha receptor agonist, it can restore the tension of blood vessels, relieve edema, excite β₂ receptor to relieve bronchiospasm and increase cardiac contractility at the same time, inhibit the release of leukotriene and histamine, and the inflammatory mediators, etc. Epinephrine are the first choice to rescue anaphylactic shock. Allergic lead to deaths are usually due to delayed or did not use of epinephrine, it rarely associated with overdose.

References

1. Berroa F, Lafuente A, Javaloyes G, et al. The incidence of perioperative hypersensitivity reactions: a single-center, prospective, cohort study. Anesthesia and analgesia 121 (2015): 117-123.
2. Krombach J, Hunzelmann N, K?ster F, et al. Anaphylactoid reactions after cisatracurium administration in six patients. Anesth Analg 93 (2001): 1257-1259.
3. Toh KW, Deacock SJ, Fawcett WJ. Severe anaphylactic reaction to cisatracurium. Anesth Analg 88 (1999): 462-464.
4. Clendenen SR, Harper JV, Wharen RE, et al. Anaphylactic reaction after cisatracurium. Anesthesiology 87 (1997): 690-692.
5. Briassoulis G, Hatzis T, Mammi P, et al. Persistent anaphylactic reaction after induction with thiopentone and cisatracurium. Paediatr Anaesth 10 (2000): 429-434.
6. Kounis N, Kounis G. Anaphylactic cardiovascular collapse during anesthesia: the Kounis acute hypersensitivity syndrome seems to be the most likely cause. J Korean Med Sci 28 (2013): 638-639.
7. Johansson SG, Bieber T, Dahl R, et al. Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organization, October 2003. J Allergy Clin Immunol 113 (2004): 832-836.
8. 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 99 (2004): 536-545.
9. Nel L, Eren E. Peri-operative anaphylaxis. Br J Clin Pharmacol 71 (2011): 647-658.
10. Toh KW, Deacock SJ, Fawcett WJ. Severe anaphylactic reaction to cisatracurium. Anesth Analg 88 (1999): 462-464.
11. Kroigaard M, Garvey LH, Gillberg L, et al. Scandinavian clinical practice guidelines on the diagnosis, management and follow-up of anaphylaxis during anaesthesia. Acta Anaesthesiol Scand 51 (2007): 655-700.