1. O046: Intraoperative Anaphylaxis secondary to Bacitracin Irrigation
Keith A. Sacco, M.D.1; Thanai Pongdee, M.D.2 1Department of Internal Medicine, Mayo Clinic, Jacksonville, FL 2Department of Allergy and Immunology, Mayo Clinic, Rochester, MN
American College of Allergy, Asthma & Immunology 2016 Annual Scientific Meeting
14th November 2016
test

2. Declaration of Interest
Nothing to disclose

3. Case Presentation 67yo male, urologic surgery
Reports allergy to PCN and sulfa
History of prostate CA s/p prostatectomy
History of CAD, HTN, and type II DM
Prior surgeries without incident

4. Case Presentation 80 minutes into procedure
developed hypotension with BP 80/40mmHg, tachycardia HR 140bpm, deoxygenation (spO2 92%).
Concerns for MI, PE, ?allergic reaction
Treated with pressors, albumin, hydrocortisone, diphenhydramine

5. Case Presentation Obtain tryptase, urine N-methylhistamine
Clinically stabilized, extubated, admitted to ICU
No other issues, discharged following day

6. Case Presentation Serum Tryptase 28.5 (<11.4ng/mL)
Obtain tryptase, urine N-methylhistamine
Clinically stabilized, extubated, admitted to ICU
No other issues, discharged following day
Serum Tryptase 28.5 (<11.4ng/mL)
Urine N-methylhistamine 1036 (ref )

7. Case Presentation Abnormal vitals noted at 8:55AM Medications
Chlorhexidine
Propofol – 7:40AM
Midazolam – 7:40AM
Gentamicin – 7:46AM infused over 15min
Vancomycin – 8:03AM infused over 90min
Bacitracin/polymyxin irrigation – 8:40AM

8. Case Presentation Abnormal vitals noted at 8:55AM Medications
Chlorhexidine
Propofol – 7:40AM
Midazolam – 7:40AM
Gentamicin – 7:46AM infused over 15min
Vancomycin – 8:03AM infused over 90min
Bacitracin/polymyxin irrigation – 8:40AM
Order of reaction, last medication not necessarily one to cause anaphylaxis

9. Perioperative Anaphylaxis

10. Perioperative Anaphylaxis
Difficult to assess due to rapid, successive use of multiple medications
Challenges with recognition
Surgical draping
Inability of anesthesized patient to verbalize symptoms
Multiple physiologic changes during surgery that could mask or emulate anaphylaxis
Critical to thoroughly analyze anesthesia records

11. Perioperative Anaphylaxis Epidemiology
Incidence with general anesthesia varies from 1:10,000 to 1:20,000
More common in women; no gender difference in children
Severity greater than anaphylaxis in general
Estimated mortality 1.4%-6%
Additional morbidity of 2% with brain damage
Risk factors: atopy (not for NMBAs), prior hx of anaphylaxis, drug allergy, or multiple prior procedures
Liebermann P, et al. Ann Allergy Asthma Immunol 2006; 97:

12. Perioperative Anaphylaxis Differential diagnosis
Drug overdose and interactions
Cardiac/vascular drug effects
Asthma
Arrhythmia
Myocardial infarction
Pericardial tamponade
Pulmonary edema
Pulmonary embolism
Tension pneumothorax
Hemorrhagic shock
Venous embolism
Sepsis
C1 esterase inhibitor deficiency
Mastocytosis
Malignant hyperthermia, Hyperkalemia
Myotonias

13. Perioperative Anaphylaxis Etiologic agents
Neuromuscular blocking agents
Latex
Antibiotics (β-lactams)
Hypnotics (propofol, thiopental)
Opiates
Aspirin and NSAIDs
Colloids
Chlorhexidine and antiseptics
Local anesthetics
Protamine and Heparin
Dyes (methylene blue)
Oxytocin
Aprotinin

14. Perioperative Anaphylaxis – European Data
Mertes PM, et al. JACI 2011;128:

15. Perioperative Anaphylaxis – Mayo Clinic Data
Findings consistent with other studies, in EU studies NMBA most common, in few US studies Abx are most common
Gurrieri C, et al. Anesth Analg 2011;113:

16. Perioperative Anaphylaxis Evaluation
History is of utmost importance
Allergy skin testing
No value for non-IgE-mediated rxns
May be uninformative if negative
Rule out irritant reaction if positive
Delay skin testing 4-6 weeks to avoid refractory period
Serum tryptase within 2-4 hours

17. Perioperative Anaphylaxis Histamine and Tryptase
French survey of 1253 patients with perioperative allergic reactions
Histamine and tryptase measured in 599 cases
Histamine
(% elevated)
Tryptase
IgE-mediated
78.2%
60.5%
Non-IgE-mediated
42.0%
10.6%
If tryptase negative does not rule out anaphylactic reaction, specific not sensitive. Difficult to measure histamine due to rapid degradation
Dong SW et al. Minerva Anestesiol 2012;78:

18. General precautions for future procedures
Asthma should be as well controlled as possible
Avoid beta-blockers if possible
Consider avoidance of ACE inhibitors
Infuse drugs that can cause direct release of histamine from mast cells and basophils (e.g. morphine, vancomycin, quaternary NMBAs) as slowly as possible
Antibiotics should be administered slowly with initial doses prior to induction of anesthesia
Verify baseline tryptase is not elevated
Review anesthesia records, use medication that was skin test negative

19. Conclusion
Allergy skin testing (-): Chlorhexidine, Propofol, Midazolam, Gentamicin, Vancomycin, Polymyxin
Bacitracin: 21mm x 17mm
Histamine: 8mm x 11mm
HSA: 0
Baseline tryptase checked - normal
Subsequent surgery without adverse reactions

20. References Dong SW et al. Minerva Anestesiol 2012;78:868-78.
Gurrieri C, et al. Anesth Analg 2011;113:
Liebermann P, et al. J Allergy Clin Immunol 2005; 115 (Suppl): S483-S523.
Liebermann P, et al. Ann Allergy Asthma Immunol 2006; 97:
Mertes PM, et al. JACI 2011;128:

21. Questions & Discussion Sacco.Keith@mayo.edu