Anaphylactic Shock in General Anesthesia

General Data

16 y/o , Indian Female , 40 kgwNo underlying comorbidHx of allergy to ? Antibiotics –generalized rashesNo history of previous surgery

General Data Diagnosed to have: frontoethmoidal mucocele

Planned for: FESS

Before op: requested by surgeon for controlled hypotension, propofol infusion for maintenance and tranexemic acid prophylaxis

General anesthesia was done . Induction with Fentanyl 80 ug , propofol 100mg, atracurium 30mg , morphine 3mg

General Data Maintenance:

isoflurane 1.0 propofol infusion –running at 30-50mg/H atracurium 10mg (stat dose at 30 and 1 H

after induction) - in 1st hour of op: Bp: 90-100/50-60, MAP: 60-70 no episode of hypotension HR: 90-110 ET CO2 : 32-40 SpO2 : 99-100

General Data

At 1H of op: 1g tranexemic acid given (was put in 300cc NS infusion)

After 10min: noted ETCO2 wave showed bronchospasm, no desaturation

-increase isoflurane flow BP: 60/40, reduce isoflurane,

bronchospasm resolved but BP further decrease despite

ephedrine 6mg x2 given

General Data

Pulse : weak ECG: sinus tachycardia HR 120-130 BP drop to 43/24 (MAP 30)SpO2 : 99% wave form: pulsus paradoxusEtCO2: waveform normal 32-34

Given IV adrenaline 1:10,000 x1ml twice

General Data

Subsequently after few minutes

Sp O2: waveform normal

99%

BP: pick up

60/40- 80/60

HR : 100-110

Operation finished after 1H 15min, patient extubated well, discharged to general ward

What Happened ?

Anaphylactic shock secondary to

Tranexemic acid

Anaphylaxis during anesthesia

Definition Anaphylaxis : rapid, generalized immunologically mediated events involving an antigen-specific IgE-mediated mechanism that occur after exposure to foreign substances in

previously sensitized persons

Anaphylaxis during anesthesia

The incidence of anaphylaxis in GA is about 1:5000 to 1: 20000 and with a mortality rate of up to 6% Mechanism : 1.Specific IgE cross-linked by allergen (drug)

2. Complement activation by specific IgG or IgM binding to antigen (drug)

3. Direct complement activation by way of the alternate pathway

4. Direct activation of mast cells or basophils

CAUSES OF ANAPHYLAXIS AND ANAPHYLACTOID REACTIONS DURING ANESTHESIA

Causes Rate of Reaction (%)

Muscle relaxants 61.6

Latex 16.6

Antibiotics 8.3

Hypnotics 5.1

Colloids 3.1

Opioids 2.7

Other (aprotinin, ethylene oxide, local anesthetics)

2.6

Data from French survey by Perioperative Anaphylactoid Reactions Study Group; 1648 patients, July 1994 to December 1996.

Latex

High-risk groups:

1.Health-care workers or other occupational exposure

2.Multiple surgical procedures

3.Atopic patients

4.Fruit allergy

Colloids

Prior drug allergy and male

Gelatins(0.34%) and dextrans(0.27%) more likely than albumin(0.1%) and hetastarch(0.06%)

Pathophysiology

Multiple organ systems are affected

Initial exposure to antigen → IgE production and bind to mast cells and basophils

Reexposure → release of mediators from mast cells and basophils

Management

From FDA reports: Tranexamic acid and Shock - anaphylactic

This is a study of Shock - anaphylactic (Anaphylaxis) among people who take Tranexamic acid. The study analyzes: the time on Tranexamic acid when people have Shock - anaphylactic, age of these people, the severity of Shock - anaphylactic, how they recovered, and common conditions and drugs used besides Tranexamic acid. In total 1,505 Tranexamic acid users are studied. The study is created by eHealthMe based on reports from FDA and is updated regularly.

From FDA reports: Tranexamic acid and Shock - anaphylactic

Tranexamic acid has active ingredients of tranexamic acid. Commonly reported side effects of Tranexamic acid include haemoglobin decreased, fever, rectal haemorrhage, melaena, vaginal haemorrhage.

Shock - anaphylactic has been reported by people with multiple sclerosis, asthma, blood pressure management, high blood pressure, premedication.

From FDA reports: Tranexamic acid and Shock - anaphylactic

1,505 people reported to have side effects when taking Tranexamic acid. Among them, 19 people (1.26%) have Shock - Anaphylactic.

From FDA reports: Tranexamic acid and Shock - anaphylactic

From FDA reports: Tranexamic acid and Shock - anaphylactic

Pulsus paradoxus

Pulsus paradoxusDuring inspiration, the right ventricle distends due to increased venous return, the interventricular septum bulges into the left ventricle reducing its size (reversed Bernheim effect), and increased pooling on blood in the expanded lungs decreases return to the left ventricle, decreasing the stroke volume of the left ventricle.

Additionally, negative intrathoracic pressure during inspiration is transmitted to the aorta. The relatively higher negative pressure in the pulmonary circulation compared to the left atrium in patients with pericardial pathology causes back flow of blood from the left atrium into the pulmonary veins during inspiration.[2]

Therefore, during inspiration the fall in the left ventricular stroke volume is reflected as a fall in the systolic blood pressure. The converse is true for expiration. During quiet respiration, the changes in the intrathoracic pressures and blood pressure are minor. The accepted upper limit for fall in systolic blood pressure with inspiration is 10 mmHg.

Pulsus paradoxusCardiac causes

1. Cardiac tamponade2. Pericardial effusion3. Constrictive pericarditis4. Restrictive cardiomyopathy[4]5. Pulmonary embolism6. Acute myocardial infarction7. Cardiogenic shock

Extracardiac pulmonary causes

1. Bronchial asthma2. Tension pneumothorax

Extracardiac non-pulmonary causes

1. Anaphylactic shock

2. Volvulus of the stomach[6]3. Diaphragmatic hernia[6] 4. Superior vena cava obstruction[4]5. Extreme obesity

Thanks for your Attention !!