GA4-90
Anaphylaxis to Sevoflurane
1Rost J, 2Johnson G
1Cooper University Hospital, Camden, NJ, United states of america; 2The Children's Hospital of Philadelphia, Philadelphia, PA, United states of america
Summary
Anaphylaxis to inhaled volatile anesthetics is rare, with only one reported case of anaphylaxis to isoflurane. We present a patient with history of anaphylaxis to sevoflurane, who presented for bilateral myringotomy & tubes (BMT), and tonsillectomy for recurrent tonsillitis. She had previously experienced periorbital/perioral edema following exposure to sevoflurane, and been evaluated by an allergist for causes of her perioperative edema. Although she exhibited mildly elevated IgE levels, other lab work remained normal, suggesting true anaphylaxis to sevoflurane.
Case History
Our patient presented to us with a history of idiopathic angioedema, amplified musculoskeletal pain syndrome, and recurrent tonsillitis. Her surgical history includes BMT, division of tongue tie, adenoidectomy, and dental extraction (latter two at our institution). Her initial BMT was uncomplicated, consisting of sevoflurane by mask. Her division of tongue tie had a normal intraop course; however, she experienced perioral and periorbital edema in PAC, leaving with a diagnosis of angioedema. During her adenoidectomy, she developed oropharyngeal and periorbital edema upon induction with sevoflurane. She required treatment with steroids, epinephrine infusion, and admission to the PICU. Her immunology work-up resulted in largely normal blood work, yielding only elevated IgE-antibody levels, but normal tryptase, C1E, C4 and C3 compliment levels - immunology diagnosing her with anaphylaxis to sevoflurane. Her subsequent anesthetic for dental extraction was performed successfully with IV placement and an intravenous anesthetic.
Our plan was awake IV placement with intravenous propofol for maintenance. She received, midazolam 15 mg PO to little effect. She was provided inhaled nitrous oxide for IV placement, but she experienced severe anxiety, choking, and coughing. We were unable to talk her through an awake IV placement, necessitating IM ketamine. She tolerated intravenous induction with propofol and maintenance with propofol infusion. Upon emergence, she was extubated to nasal cannula, and transported to the PICU where she was monitored overnight. Having met discharge requirements, and without any episodes of rash, edema, coughing, wheezing, or hypotension, she was discharged home the next day.
Discussion
Anaphylaxis to volatile anesthetic is an exceedingly rare complication for patients requiring surgery. Anaphylaxis is typically diagnosed with positive serum tryptase level after an episode of rash, edema, bronchospasm or hypotension following exposure to an allergen. Hereditary angioedema is related to C-1-esterase deficiency and complement derangement. Her elevated IgE levels confirm the diagnosis of a type 1 immune reaction despite a normal tryptase level, now carrying a diagnosis of anaphylaxis to sevoflurane. Our patient requires total intravenous anesthesia for all future procedures, but will require an augmented premedication regimen prior to awake IV placement.
1. Csuka, D., et al. “The Role of the Compliment System in hereditary Angioedemaâ€. Molecular Immunology, vol. 89, pp 59-68, Sept 2017.
2. Slegers-Karsmakers, S., Stricker, BH. “Anaphylaxtic Reaction to Isoflurane.†Anaesthesia. Jun 1988 vol 43. pp 506-507
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