Abstract
Anafilaksi yaşamı tehdit eden, sistemik hipersensitivite reaksiyonudur. Anestezi altında anafilaksiyi tanımak güç olabilmektedir. Bu olgu ile anestezi altında gelişen anafilaksiyi tanımayı ve tedavisinin gözden geçirilmesi amaçlanmıştır.
Laparoskopik kolesistektomi planlanan 58 yaşında kadın hastanın preoperatif değerlendirmede hipertansiyon, depresyon ve kronik obstrüktif akciğer hastalığı mevcut idi. Olgu antihipertansif ve antidepresan tedavi kullanmaktaydı. Alerji öyküsü olmayan hasta operasyon odasına alınarak monitorize edildi. Anestezi indüksiyonu yapılan ve sorunsuz şekilde entübe edilen hastaya, cerrahi insizyon öncesi 1000 mg seftriakson yavaş infüzyon şeklinde uygulanmaya başlandı. 1 dakika sonra monitörde pik havayolu basıncının 20 cmH2O’dan 45 cmH2O’ya yükseldiği görüldü ve manuel ventilasyona geçildiğinde balonda ciddi bir direnç olduğu görüldü. Hastaya yeterli tidal volüm verilemedi. Olgunun her iki kol ve gövdesinin üst kısmında yaygın kızarıklık olduğu gözlendi. Anafilaksi düşünülerek antibiyotik infüzyonu durduruldu ve 0.5 mg intramusküler adrenalin ile intravenöz steroid ve antihistaminik ilaçlar uygulandı. Bu esnada hastanın satürasyonu %60’a düştü ve etCO2 değeri 8 mmHg idi. KB’si ölçülemeyen ve karotis nabzı alınamayan olgu nabızsız elektriksel aktivite (NEA) düşünülerek kardiyak arrest tanısı konuldu. Kardiyopulmoner resüsitasyona (KPR) başlandı ve arrest ritmi NEA olan olguya 1 mg adrenalin intravenöz puşe uygulandı. Yaklaşık 2 dakikalık KPR sonrası hastanın spontan dolaşımı geri döndü (SDGD). Taşikardi ve hipotansiyonu mevcut olan olguya pozisyon verilerek, hızlı kristalloid infüzyonu ve vazopressör destek olarak noradrenalin infüzyonu başlandı. Yaklaşık 4 saat sonra hemodinami ve solunum parametreleri stabil hale gelen olgu sorunsuz ekstübe edildi.
Genel anestezi altında anafilaksinin tanınması ve güncel kılavuz yönergelerine göre etkin bir tedavinin uygulanması gereklidir. Özellikle kapnografi kullanımı hem kardiyak arresti hem de SDGD’yi erken tanımada anlamlıdır. Anestezi altında monitörlerdeki en basit değişiklikler önemsenmeli ve mutlaka hastaların nabız kontrolleri yapılmalıdır.
References
- Caimmi S, Caimmi D, Bernardini R. Perioperative anaphylaxis: epidemiology. Int J Immunopathol Pharmacol. 2011;24(Suppl 3):21–6.
- Joint Task Force on Practice Parameters. Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol. 2010;105:259–73.
- Harper NJN, Cook TM, Garcez T, et al. Anaesthesia, surgery, and life-threatening allergic reactions: management and outcomes in the 6th National Audit Project (NAP6). Br J Anaesth. 2018;121(1):172- 188.
- Saritas A, Erbas M, Goven I, et al. Asystole after the first dose of ceftriaxone. Am J Emerg Med 2012;30:1321.e3-4.
- Lott C, Truhlář A, Alfonzo A, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021;161:152-219.
- Liberman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and Management of anaphylactic practice parameter: 2010 update. J Allergy Clin Immunol 2010;126:477-80.
- Thong BY, Tan TC. Epidemology and risk factors for drug allergy. Br J Clin Pharmacol 2011;71:684-700.
- Liberman P. Biphasic anaphylactic reactions. Ann Allergy Asthma Immunol 2005;95:217-26.
- Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250-78.
- Mirakian R, Ewan PW, Durham SR, et al. BSACI guidelines for the management of drug allergy. Clin Exp Allergy. 2009;39(1):43-61. doi:10.1111/j.1365-2222.2008.03155.x
Abstract
Anaphylaxis is a life-threatening and systemic hypersensitivity reaction. It can be difficult to recognize anaphylaxis under general anesthesia. With this case, it is aimed to identify anaphylaxis under anesthesia and to review its treatment.
A 58-years-old female patient who was scheduled for laparoscopic cholecystectomy had hypertension, depression and chronic obstructive pulmonary disease (COPD) in the preoperative evaluation. The patient was taking antihypertensive and antidepressant medication. Anesthesia induction was started and the patient was intubated without any problem. EtCO2 at this time was 32 mmHg. Slow intravenous infusion of 1000 mg ceftriaxone was started before the surgical incision. After 1 minute, it was seen on the monitor that the peak airway pressure increased from 20 cmH2O to 45 cmH2O and there was a serious resistance in the balloon when manual ventilation was tried. Sufficient tidal volume could not be given to the patient. During this time, the patient’s peripheral oxygen saturation rapidly decreased to 60% and the etCO2 value was 8 mmHg. It was observed that the case had widespread redness on both arms and the upper part of the trunk. Antibiotic infusion was stopped due to anaphylaxis and 0.5 mg intramuscular adrenaline and intravenous steroid and antihistamine drugs were administered. The patient whose blood pressure (BP) could not be measured and whose carotid pulse could not be taken was diagnosed as cardiac arrest, considering pulseless electrical activity (PEA). Cardiopulmonary resuscitation (CPR) was started and intravenous 1 mg adrenaline was administered to the patient whose arrest rhythm was PEA. After 2 minutes of CPR, return of spontaneous circulation (ROSC) of patient has obtained. Crystalloid and noradrenaline infusion was started in the patient with tachycardia and hypotension. The patient whose hemodynamic and respiratory parameters stabilized after 4 hours, was extubated without any complication.
It is necessary to recognize anaphylaxis under general anesthesia and to provide an effective treatment according to current guidelines. In particular, the use of capnography is significant in the early recognition of both cardiac arrest and ROSC. Changes in the monitors of patients under general anesthesia should be considered in terms of anaphylaxis.
References
- Caimmi S, Caimmi D, Bernardini R. Perioperative anaphylaxis: epidemiology. Int J Immunopathol Pharmacol. 2011;24(Suppl 3):21–6.
- Joint Task Force on Practice Parameters. Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol. 2010;105:259–73.
- Harper NJN, Cook TM, Garcez T, et al. Anaesthesia, surgery, and life-threatening allergic reactions: management and outcomes in the 6th National Audit Project (NAP6). Br J Anaesth. 2018;121(1):172- 188.
- Saritas A, Erbas M, Goven I, et al. Asystole after the first dose of ceftriaxone. Am J Emerg Med 2012;30:1321.e3-4.
- Lott C, Truhlář A, Alfonzo A, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021;161:152-219.
- Liberman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and Management of anaphylactic practice parameter: 2010 update. J Allergy Clin Immunol 2010;126:477-80.
- Thong BY, Tan TC. Epidemology and risk factors for drug allergy. Br J Clin Pharmacol 2011;71:684-700.
- Liberman P. Biphasic anaphylactic reactions. Ann Allergy Asthma Immunol 2005;95:217-26.
- Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250-78.
- Mirakian R, Ewan PW, Durham SR, et al. BSACI guidelines for the management of drug allergy. Clin Exp Allergy. 2009;39(1):43-61. doi:10.1111/j.1365-2222.2008.03155.x
Details
| Primary Language | Turkish |
|---|---|
| Subjects | Anaesthesiology |
| Journal Section | Case Reports |
| Authors | |
| Publication Date | May 29, 2023 |
| Published in Issue | Year 2023 Volume: 2 Issue: 1 |
