Case reports:

Case 1: “Patient required urgent surgery for empyema. On amoxicillin and metronidazole. Mildly hypotensive following induction of anaesthesia. Treated with fluid and metaraminol.  Easy FM ventilation.  Intubated with 41Ch L DLT, position confirmed with waveform capnography, but high airway pressure alarm on ventilator, rapid desaturation and marked hypotension.  Called for help.  Chest examined; bilateral wheeze/crackles.  Increasingly difficult to ventilate, purulent sputum +++ observed in ETT so suctioned, but still difficult to ventilate and severely hypoxic/cyanosed therefore DLT removed and hand ventilated in case DLT obstructed.  Simultaneously to this 50mcg adrenaline given due to hypotension refractory to multiple boluses metaraminol.  Able to hand ventilate via FM.  Rapid recovery of oxygenation and BP following adrenaline and chest much improved on auscultation.  Reintubated with single lumen COETT… Reviewed incident…  Pt suffered no/low harm as per CT governance anaesthetic lead.  Referral form for anaphylaxis attached, however tryptases not completed.  On ICE NO tryptase rise thus less likely anaphylaxis.  Possible extreme histamine release to atracurium with bronchospasm/hypoxia leading to peri-arrest situation, or tube blockage leading to same events as per reporter.  Will ask anaphylaxis lead re likelihood of anaphylaxis on this basis and onward referral to [allergy service]. Possible anaphylactic reaction following induction of anaesthesia, noted severe chest infection with empyema present, hence difficult to differentiate. Appropriately acted upon. Anaphylaxis and supportive treatment instituted with good effect. Anaphylaxis referral done. Investigations performed.”

Case 2: “Patient scheduled for elective surgery (total laryngectomy plus neck dissection and pectoral flap). Patient assessed as ASA-4, fragile with multiple comorbidities and allergies (anaphylactic type) to a broad range of drugs (antibiotics, NSAIDs, neuroleptics). Initial management of awake tracheostomy successful, with no incidents. During team brief antibiotic cover is discussed: as the patient refer anaphylactic reaction to penicillins and cephalosporins as well as clindamycin, the decision is made to use teicoplanin (in normal use of diluted in 250ml bag of fluid), metronidazole, and gentamicin. Stable throughout the administration of gentamicin and metronidazole, at the beginning of teicoplanin, started to be evident that airway pressures are increased, and rapidly the peripheral pulse trace of the invasive blood pressure is lost. No initial response to metaraminol, and recognising the situation as anaphylaxis, the alarm is sounded, crash trolley in… and help is immediately available with senior anaesthetists and on call ICM Consultant. Started CPR immediately due to the lack of proper recordable blood pressure. Pads of defib applied. Hydrocortisone 100mg iv given. Fluids infusions started, Adrenaline boluses given. In total 8 mg of adrenaline for a total of 35 min downtime. Initial stability gained through the 6-7 mg of AD and the 5th litre of fluid. CVL under US inserted, AD infusion started and later on Vasopressin. Stability after ROSC with no further episodes of desaturation, low BP or instability. EtCO2 present at all times throughout the management of the reaction. Change of flexible surgical trache tube for formal trache tube and transfer to ICU, sedated and ventilated.”

Commentary

The organisation’s own review identified good teamwork during CPR, with leadership moving between consultants, with no evident delays in treatment.  There were no issues accessing equipment.  The Quick Reference Handbook was not accessed during the resuscitation; it was not clear why.  The team had a debrief after the event followed by a later formal debrief where some learning points were identified. There was good recognition and declaration of emergency with appropriate calls for help. Good support attended, with excellent teamwork recognising the importance of leadership, and closed loop communication. Good contemporaneous documentation by appointment of a 'scribe'. Allergy status had been discussed at team brief, and an appropriate plan was made for prophylaxis; the microbiologists agree they would have advised the same combination.  The team engaged with all elements of the Safer Surgery Checklist.  The patient made a good recovery from the episode without neurological injury, but is now on a non-surgical pathway for ongoing treatment.

NAP 6 [1] identified teicoplanin as a significant causative agent for anaphylaxis during anaesthesia. In this case, it seems good preparation and good teamwork produced a good outcome. It is worth pointing out that the latest guidelines on anaphylaxis do not include hydrocortisone; prompt administration of adrenaline is key and nothing should delay that. The latest version of the Association of Anaesthetists Quick Reference Handbook [2] includes this change.

Readers might consider the barriers to use of the QRH that exist in their own departments and what could be done to remove them. For example: simulation, “table top” exercises, checking prominent placement, educating related staff groups such as ODPs. The reporters said a scribe was appointed but we may all need more practice at assigning a reader of the QRH including consideration of who that would be and how that fits into the work flow of the resuscitation.