Case reports:

Case 3: “Patient presented for fem-pop bypass electively.  On induction of anaesthesia was given 100ug fentanyl followed by 100mg of propofol and 35mg atracurium (both given about 1 minute post fentanyl). Initially noticed a diffuse red rash around the patients face and commented that we should not give further atracurium. The 1st blood pressure did not record but patient had a peripheral pulse. We proceeded to intubation as we thought this would cause a sympathetic response, intubation was successful and no sign of bronchospasm, anaesthesia maintained with isoflurane. Blood pressure recorded as systolic of 50 so 1mg metraminol given and fluid bolus and patient positioned head down, a repeat dose of 0.5mg followed by 9mg ephedrine given. A further blood pressure recorded systolic of 50. Adrenaline 50mcg given - despite an increase in heart rate the peripheral pulse disappeared. Blood pressure recorded of 30 systolic, no palpable pulse and loss of sats trace (co2 maintained).   Declared cardiac arrest and pulled the emergency buzzer. Pads applied and patient PEA on ECG monitor. The rest of the adrenaline syringe given (950 mcg). Patient got ROSC after roughly 2 minutes of CPR. Blood pressure recovered to a systolic of 160 and remained maintained around their normal value for that point. Decision to abandon operation and take to ICU - patient successfully extubated in the meantime.  Discuss with patient had a referral to allergy team completed.”

The case illustrates the importance of using adrenaline as the first line vasopressor in cardiovascular collapse due to suspected anaphylaxis, commencing CPR if the systolic blood pressure is 50 mmHg or less [1].

Case 4: “Patient was induced for orthopaedic surgery. NKDA. She developed high airway pressures and a low blood pressure following teicoplanin (approx 400mg given). The likely anaphylaxis was recognised, surgery was stopped, adrenaline (50mcg boluses) were administered and the emergency buzzer was pulled... Possible anaphylaxis treated correctly”

Case 5: “Cardiac arrest in theatre following administration of antibiotics. Probably anaphylaxis”  

Commentary

All of these cases remind us that anaphylaxis can present to any of us at any time and that it is important to have the right equipment, drugs and cognitive aids immediately available.

References:

[1] Anaesthesia, Surgery and Life-Threatening Allergic Reactions: Report and Findings of the Royal College of Anaesthetists’ 6^th National Audit Project- Perioperative Anaphylaxis Royal College of Anaesthetists, London 2018 [Accessed 4/1/2024]

[2] Quick Reference Handbook. Association of Anaesthetists, 2023