Perioperative anaphylaxis manifesting as cardiac arrest during cardiac surgery

Perioperative anaphylaxis is a serious entity with high morbidity and mortality. Perioperative anaphylaxis can be caused by any of the multitude of medications and substances used in anesthesia and surgery, and the most common causes include neuromuscular blocking agents, antibiotics, antiseptics, latex, and dyes. The differential diagnosis of perioperative anaphylaxis is wide from both an immunologic and a nonimmunologic standpoint. The majority of the intraoperative anaphylaxis reactions are thought to be immunoglobulin E (IgE) mediated; however, other primary non-IgE-mediated mechanisms can also be present. Clinical manifestations can vary from mild cutaneous exanthema to cardiac arrest. Tryptase can be helpful in identifying perioperative anaphylaxis. In this article, we present the case of a 75-year-old man who had a cardiac arrest without skin symptoms perioperatively during coronary artery bypass surgery. We describe the presentation, strategic evaluation, and subsequent management with recommendations for future surgery based on his evaluation and the identified culprit. Subsequent surgery was later completed. Understanding the clinical presentation, key components of testing, and recommendations for future management of perioperative anaphylaxis are invaluable skills that the allergist can provide for the patient and the anesthesia and surgery teams.