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Persistent anaphylactic reaction after induction with thiopentone and cisatracurium
G Briassoulis1, T Hatzis, P Mammi
1Paediatric Intensive Care Unit, 'Aghia Sophia' Children's Hospital, Levadias and Thivon Street, 11527 Athens, Greece.
Insights
A child experienced a severe allergic reaction to cisatracurium, a new anesthetic drug, during surgery. This IgE-mediated anaphylaxis required epinephrine infusion and highlights challenges in diagnosing anesthetic drug allergies in pediatric patients.
Area of Science:
- Anesthesiology
- Pediatric Allergy
- Clinical Immunology
Background:
- Phimosis surgery in a 6-year-old boy.
- Standard anesthetic induction with thiopentone and neuromuscular blockade with cisatracurium.
- No prior exposure to anesthetic agents or known allergy history.
Observation:
- Development of severe, persistent bronchospasm and central cyanosis post-drug administration.
- Refractory bronchial hyperresponsiveness necessitating continuous epinephrine infusion.
- Absence of prior sensitization to anesthetic drugs.
Findings:
- Diagnosis of an IgE-mediated anaphylactic reaction to cisatracurium.
- Elevated serum markers: eosinophil cationic protein, tryptase, histamine, and cisatracurium-specific IgE.
- First reported case of anaphylaxis to cisatracurium in a pediatric patient.
Implications:
- Anaphylactic reactions to novel anesthetic agents can be difficult to identify during pediatric general anesthesia.
- Early recognition and prompt management are crucial for life-threatening allergic reactions.
- Understanding the pathogenesis and diagnosis of anaphylaxis to intravenous anesthetics is vital for patient safety.
Abstract:
A 6-year-old boy presented for surgery for phimosis. The anaesthetic technique included intravenous induction with thiopentone and neuromuscular blockade with cisatracurium. Severe persistent bronchospasm and central cyanosis followed the administration of these drugs. A continuous i.v. infusion of epinephrine at 0.2 microg. kg(-1) x min(-1) was necessary to break the severe refractory bronchial hyperresponsiveness. There was no previous exposure to anaesthetic drugs and no definite family history of allergy. Through increased serum eosinophil cationic protein, tryptase and histamine levels and IgE levels specific to cisatracurium, we demonstrated an IgE-mediated anaphylactic reaction to cisatracurium in the child's first exposure to this new neuromuscular blocking agent. Anaphylactic reactions to new anaesthetic drugs may be challenging to recognize and treat during general anaesthesia in children. The pathogenesis, diagnosis and management of life threatening persistent allergic reactions to intravenous anaesthetics are discussed.