induced anaphylaxis during cardiopulmonary bypass

Anaesth Intensive Care 2011; 39: 492-495

Quantification of volume loss and haemodynamic changes of Gelofusine®-induced anaphylaxis during cardiopulmonary bypass @-%EZN@[VO;%F-%>NUZV\@O;%N-%]-%?NQ%Q\V[V@[T;%F-%FZN22O Departments of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands and Fremantle Hospital, Perth, Western Australia

>^..N@_ A patient undergoing anaesthesia for coronary artery bypass surgery developed what was subsequently confirmed to be an anaphylactic reaction to succinylated gelatin (Gelofusine®). By virtue of being on cardiopulmonary bypass, rapid detection, quantification and treatment of volume loss (by vasodilatation and extravasation) was possible. The patient required 51 ml/kg of resuscitative fluids in the 15 minutes after onset of anaphylaxis, or 73% of her calculated preoperative blood volume. Alpha-adrenoceptor agonists and vasopressin were required to manage ongoing vasoplegia. This case emphasises the importance of volume resuscitation and vasopressors in the treatment of anaphylaxis. [/:%],+$)W%&(&43:0&B#);%S/0,6")#(/®, cardiopulmonary bypass

One of the mainstays in the treatment of cardiovascular collapse in anaphylaxis is aggressive !"#$% &$'#(#)*+&*#,(-% ./$#&*,+)% +/0/&)/$% $"+#(1% anaphylaxis produce peripheral vasodilatation and increase capillary permeability resulting in a mixed distributive-hypovolaemic shock pattern123#)% +/4,+*% ,"*0#(/)% &% 5&)/% ,6% 5,(7+'/$% Gelofusine®8#($"5/$%9)"55#(:0&*/$%1/0&*#(;%"C)/G"/(*% investigations demonstrated triple-vessel coronary artery stenosis with mild hypokinesis of the apical septum but otherwise preserved left ventricular systolic and diastolic function with normal heart =&0=/)-% Two months after admission she was scheduled for coronary artery bypass grafting with CPB using )&43/(,")%=/#(%&($%#(*/+(&0%'&''&+:%&+*/+:%1+&6*)-% Her weight was 72 kg and preoperative haemoglobin 5,(5/(*+&*#,(%9ICA%'/&)"+/$%JKL%1M0Induction of anaesthesia was uneventful and coronary artery grafting, while on CPB, was without #(5#$/(*-% I/+% #(#*#&0% IC% &6*/+% 5,''/(5/'/(*% ,6% CPB was 57 g/l, and three units of packed cells D/+/% *+&()6")/$-% N6*/+% &(% &,+*#5% 5+,))850&'4% *#'/% of 45 minutes she was rewarmed and prepared for )/4&+&*#,(% 6+,'% C:4&))-% @/)/+=,#+% =,0"'/% D&)% 0,D% at this point and following 1000 ml of Plasma-Lyte Anaesthesia and Intensive Care, Vol. 39, No. 3, May 2011

CASE REPORT (Baxter, Toongabbie, New South Wales, Australia) )3/%D&)%*+&()6")/$%`KK%'0%,6%S/0,6")#(/Within one minute of commencement of the Gelofusine bolus her mean arterial blood pressure fell from 60 mmHg to 30 mmHg and the return to *3/% +/)/+=,#+% ,6% *3/% C:4&))% 5#+5"#*% $/5+/&)/$-% 23/+/% was a concurrent fall in the patient’s central =/(,")% 4+/))"+/% 6+,'% a% *,% L% ''I1-% >"+1#5&0% &($% circuit-related causes of low venous return were

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excluded and a presumptive diagnosis of Gelofusine &(&43:0&B#)%D&)%'&$/%9P#1"+/%JAThe Gelofusine infusion was ceased and 3:$+,5,+*#),(/% YKK% '1% D&)% &$'#(#)*/+/$-% b=/+% *3/% next 15 minutes, the patient received adrenaline in 100 to 500 µg boluses to a total of 3 mg and phenylephrine in 500 µg boluses to a total of L% '1-% Q,+&$+/(&0#(/% &($% &$+/(&0#(/% #(6")#,()% D/+/% 5,''/(5/$-% >3/% D&)% &0),% &11+/))#=/0:% +/)")5#*&*/

%$Cooled to 32°C Rewarming Separation CPB onset commenced Anaphylaxis from CPB

Significant events

Transferred to ICU 120 110 90

16

80

14

70

12

60

10

50

8

40

6

30

4

20

2

10

2000

6.5

1800

6

1600

5.5

1400

5

1200

4.5

1000

4

800

3.5

600

3

400

2.5

200 1000

700

Cardiac output (l/min)

2

0

Adrenaline (µg/h) Noradrenaline (µg/h)

50

Vasoactive drugs

800

0 50 00 1000 10 0 0 10

Vasopressin (U)

900

Mean arterial blood pressure (mmHg)

2

Boluses Adrenaline(mg) Phenylephrine (µg) 1 1 1

600

1

1

1

230

240

210

220

200

180

190

160

170

150

140

130

110

120

2 1 1

FFP (units)

1 1

CSL (ml) Plasmalyte (ml)

Vasopressin (units/h)

Time after onset of CPB (minutes)

Fluids Blood (units)

90

0

Awake Prior to onset of CPB

100

1 70

2

100

80

200

60

3

30

4

300

20

5

400

10

0

500

50

Systemic vascular resistance (dyn.s.cm–5)

100

18

40

Central venous pressure (mmHg)

20

500 0 500 0

Gelofusine (ml)

500

1000 0 1000 500

FIGURE 1W%I&/',$:(&'#5%53&(1/)-% EF3/% 3&$% )#1(#75&(*% 4/+#43/+&0% ,/$/'&% D3#53% +/),0=/$% ,=/+% several days and made a complete recovery with no (/"+,0,1#5&0%$/75#*-%>3/%D&)%$#)53&+1/$%6+,'%3,)4#*&0% *D,%D//H)%&6*/+%)"+1/+:.&)*%5/00%*+:4*&)/%0/=/0)%4/&H/$%&*%Lg-f%h1M0%9(,+'&0% iJf%h1M0A;%,(/%3,"+%&6*/+%*3/%,()/*%,6%*3/%&(&43:0&B#)-% Two months after surgery, allergy testing was under*&H/(-%>H#(%4+#5H%&($%#(*+&$/+'&0%)H#(%*/)*#(1;%")#(1% P#)3/+j)% F+,*,5,0)2;% 5,(7+'/$% S/0,6")#(/% &)% *3/% causative agent with marked serpiginous weals with )"++,"($#(1%!&+/)%$/=/0,4#(1%&*%C,*3%S/0,6")#(/%*/)*% )#*/)Consent was obtained from the patient to publish *3#)%+/4,+*U\>E^>>\bQ Gelofusine allergy is well described, usually occurring during anaesthesia or resuscitation3-6-% 23#)% ,6*/(% '&H/)% $#&1(,)#)% &($% *+/&*'/(*% $#675"0*% $"/% *,% 5,(6,"($#(1% 4&*3,43:)#,0,1#5&0% )*&*/)-% 23/% /B&5*% mechanism is largely unknown, but both IgE and non-IgE mechanisms have been postulated5-% \*% #)% estimated that the incidence of allergic reactions to 1/0&*#(8C&)/$%),0"*#,()%#)%K-KLak7In this case, adrenaline 3 mg, phenylephrine 3 mg &($%LgaK%'0%,6%!"#$%96,"+%"(#*)%4&5H/$%+/$%5/00);%*D,%

"(#*)%PPF%&($%Y%0#*+/)%F0&)'&0:*/A%D/+/%1#=/(%#(%*3/% 7+)*%J`%'#("*/)%,6%*3/%+/&5*#,(%*,%'&#(*&#(%+/)/+=,#+% 0/=/0)We estimated her normal circulating blood volume *,% C/% `-Kf% 0#*+/);% &))"'#(1% *3&*% C0,,$% =,0"'/% #)% 70 ml/kg in the non-obese8-%23/%=,0"'/%,6%*3/%C:4&))% 5#+5"#*% D&)% Y-f% 0#*+/)-% 23/% =,0"'/% ,6% +/)")5#*&*#,(% !"#$)% 1#=/(% #(% *3/% 7+)*% J`% '#("*/)% *3/+/6,+/% +/4+/)/(*/$% fe-fk% ,6% 3/+% 5#+5"0&*#(1% EF?@-% N0*3,"13% *3/:% measured a massive increase in endogenous 5&*/53,0&'#(/%0/=/0);%#*%D&)%(,*%)"675#/(*%*,%&**/("&*/% *3/% /66/5*% ,6% *3/% 3#)*&'#(/-% 23/% 5&)/% D&)% "(")"&0% )#(5/%+/)")5#*&*#,(%D&)%D#*3%!"#$%&0,(/%D#*3%&%+/*"+(% to normal haemodynamic parameters concomitant with a fall to normal in the plasma histamine level &*%&+,"($%YK%'#("*/)Loss of circulating volume in anaphylaxis is due to a combination of increased capillary permeability D#*3%!"#$%/B*+&=&)&*#,(%#(*,%*3/%#(*/+)*#*#&0%)4&5/%&($% sequestration in grossly dilated vascular beds leading *,% &% 4+,6,"($% +/$"5*#,(% #(% =/(,")% +/*"+(-% 23#)% mechanism was well demonstrated in this case by the transoesophageal echocardiogram showing an empty 3/&+*%/=/(%&6*/+%'&))#=/%!"#$%+/40&5/'/(*Adrenaline has mast cell stabilising and C+,(53,$#0&*#(1% /66/5*);% 50/&+0:% ,6% C/(/7*% #(% *3/% *+/&*'/(*% ,6% &(&43:0&B#)-% .,+/% +/5/(*0:% *3/+/% have been calls for guidelines in the treatment of anaphylaxis unresponsive to adrenaline to include the use of pure alpha agonists14-% \*% #)% *3,"13*% *3&*% this would more effectively treat the vasoplegia and reduce the risk of tachyarrhythmias and the beta2#($"5/$%=&),$#0&*,+:%/66/5*)%,6%&$+/(&0#(/-%]/%D,"0$% )"44,+*% *3#)% 4+,4,)/$% 53&(1/-% N% )#'#0&+% &+1"'/(*% would support the earlier use of vasopressin, for which there are a number of case reports in the literature, one paper describing its role as ‘pivotal’15This case highlights and reinforces the importance ,6%=,0"'/%+/40&5/'/(*%#(%&(&43:0&B#)-%\*%&0),%)/+=/)% as a reminder that gelatin-based colloids, which are most commonly resorted to in critical situations, '&:% 3&=/% "($/)#+&C0/% /66/5*)-% b"+% "($/+)*&($#(1% of the physiological effects of histamine and the

Anaesthesia and Intensive Care, Vol. 39, No. 3, May 2011

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responses seen in this case would support the earlier ")/%,6%&043&%&1,(#)*)%&($%=&),4+/))#(@VPV@VQEV> % J-%SN-% E&+$#,=&)5"0&+% &)4/5*)% ,6% &(&43:0&B#)W% #'40#5&*#,()% 6,+% *+/&*'/(*% &($% $#&1(,)#)-% E"++% b4#(% N00/+1:% E0#(% \''"(,0%YKK`m%`WL`e8Lgf% Y-%P#)3/+% .-% \(*+&$/+'&0% */)*#(1% &6*/+% &(&43:0&5*,#$% +/&5*#,(% *,% anaesthetic drugs; practical aspects of performance and inter4+/*&*#,(-%N(&/)*3%\(*/()#=/%E&+/%Jeafm%JYWJJ`8JYK% L-%\)C#)*/+%n;%P#)3/+%.-%N$=/+)/%/66/5*)%,6%40&)'&%=,0"'/%/B4&($/+)-%N(&/)*3%\(*/()#=/%E&+/%JeaKm%aWJf`8J`J% f-%n/(H#()%>;%E0#6*,(%.-%S/0,6")#(/%&00/+1:%o%*3/%(//$%6,+%#$/(*#6#5&*#,(-%N((%@%E,00%>"+1%V(10%YKKYm%afWYKg8YKl% `-%F/4:)%n;%F/4:)%V;%"($/+% Q;% 53"''/+% ]-% 23/% F#=,*&0% @,0/% ,6% ?&),4+/))#(% #(% @/6+&5*,+:% N(&43:0&5*#5% >3,5H-% N(/)*3% N(&01% YKKam%JKlWgYK8gYf-