1. Anaphylactic Shock On The Cath Table: Bivalirudin To Blame?
Karim Al-Azizi MD, Mohamed Abdelrahman MD, Daniel Makowski DO, Sarah Witkowski PharmD, Jamie Kerestes PharmD, Charlotte Casterline MD, Mark Bernardi DO
Geisinger Wyoming Valley Hospital, Wilkes Barre, PA, USA

2. Introduction:
Bivalirudin is a direct thrombin inhibitor and is indicated in the treatment of patients with moderate to high risk acute coronary syndromes who are undergoing early invasive management.
It is a small semisynthetic polypeptide, thus likely to have minimal antigenic potential.
There is no clear evidence for anti-body formation with bivalirudin and allergic reactions are considered to be exceedingly rare. | | | 2 2

3. Case:
73 yo male referred for a cardiac catheterization for anginal pain. Past medical history -Hypertension -Diabetes mellitus -Peripheral vascular disease with prior intervention. |

4. Case:
Cardiac catheterization revealed a high-grade 90% mid obtuse marginal lesion. For anticoagulation, a bolus of Bivalirudin of 0.75mg/kg was administered. A few minutes later, patient started complaining of burning sensation at his IV site. Intervention was then completed with successful deployment of a drug eluting stent with excellent angiographic results. |

5. Case:
It was noted that the patient's blood pressure has started to drop significantly from 160mmHg systolic to 100mmHg. Patient started complaining of mild shortness of breath and nausea. He was immediately resuscitated with IV fluids as well as epinephrine IV administration. Central venous access in the femoral vein was obtained. Patient responded well to the epinephrine and his respiratory status was monitored continuously and did not require oxygen supplementation. |

6. Case:
He was managed with IV steroids, H2 blockers, antihistamines and leukotriene inhibitors. He was started on an epinephrine continuous IV infusion and spent 2 nights in the ICU for monitoring. An allergy immunology consultation confirmed the diagnosis of an anaphylactic shock secondary to bivalirudin. This was his first exposure to bivalirudin and the third time to contrast. |

7. Conclusions:
Good history taking is vital to investigate into prior allergic reactions to prevent them. It is even more important to identify life-threatening anaphylactic reactions to medications in the catheterization lab promptly to prevent management delay and adverse outcomes. |