Immediate allergic cross‐reactivity to levobupivacaine and ropivacaine

Abstract

SummaryAllergic reactions to amide local anaesthetic agents are rare. We report the case of a 74-year-old man who suffered anaphylaxis, presenting with cardiovascular collapse, immediately after receiving regional anaesthesia on two separate occasions, the first involving the use of levobupivacaine and the second using ropivacaine. Skin testing revealed positive reactions to both levobupivacaine and ropivacaine, and negative reactions to articaine and lidocaine. Severe allergic reactions can be caused by the amide local anaesthetic drugs, levobupivacaine and ropivacaine. Allergic reactions in local anaesthetics are rare and mostly type IV hypersensitivity reactions involving specific T cells [1]. Immediate allergy to local anaesthetics is extremely rare with only one case of allergy to levobupivacaine [2] and one of allergy to ropivacaine [3] reported. There has been recent criticism of the method for testing of sensitivity to levobupivacaine [4,5] with inadequate information being provided to enable a definitive diagnosis (with the lack of a strongly positive intradermal reaction to a 1:10 000 or even a 1:1000 dilution of levobupivacaine) and a lack of exploration of alternative possible diagnoses. This case report presents a case of immediate-type allergy to amide local anaesthetic agents based on thorough screening. Case reportWe report the case of a 74-year-old man suffering from symptomatic cerebral ischaemia who underwent carotid endarterectomy. On pre-operative assessment, the patient reported no history of allergy to medication or food. He had previously undergone general anaesthesia and local anaesthesia for dental caries without incident.A cervical plexus block was performed with 22 ml levobupivacaine 0.5%, which was delivered by repeat injections. After a few minutes, the patient developed cognitive dysfunction, a convulsive seizure, cutaneous flushing and cardiovascular collapse manifested by a tachycardia to 117 beats.min )1 and hypotension to 80 ⁄ 40 mmHg. This did not respond to intravenous ephedrine (a total of 30 mg was given) nor to phenylephrine administered in repeated boluses (2.7 mg in total was given). Drug overdose was suspected and 250 ml (3 ml.kg ) intravenous 20% lipid was administered immediately, according to French Society of Anaesthesiology and Intensive Care guidelines [6]. The patient's conscious level improved rapidly (Glasgow Coma Scale of 14), as did his cardiovascular instability with his blood pressure rising to 90 ⁄ 57 mmHg. Surgery

Practical Guidelines for Perioperative Hypersensitivity Reactions

“…Although well known, they rarely induce adverse effects related to overdose or accidental intravascular administration [88]. In exceptional cases, they induce hypersensitivity reactions; these have been mainly described as relating to the amide group [39,89].…”

“…For NSAIDs, STs are only recommended for reactions pyrazolones reactions (grade of recommendation, C) [87,124]. STs can be used to diagnose hypersensitivity reactions to hypnotic drugs [125], sugammadex [126], local anaesthetics [89], and dyes [127] (grade of recommendation, C). The value of STs with opioids such as morphine to detect perioperative reactions is unclear, due to their capacity to induce non-specific histamine release (grade of recommendation, C) [116].…”

Systemic adverse reactions to local anesthetics

“…Dostupni podaci ukazuju da se skoro na svaki amidni lokalni anestetik u praksi pojavljuje alergijska reakcija, sa određenom rastućom stopom [29][30][31][32][33][34][35][36] . U slučaju sumnje na alergiju na lokalne anestetičke rastvore, preporučuje se primena čistog lokalnog anestetika, bez prisustva stabilizatora koji je mogući antigen, ili upotreba drugog anestetika.…”

“…Available data indicate that almost every amide local anesthetic in practice causes allergic reaction, with a specific growing pace [29][30][31][32][33][34][35][36] . In the case of suspected allergy to the local anesthetic solutions use of pure local anesthetic is recommended, without the presence of a stabilizer which is a potential antigen, or use of a different anesthetic.…”

Amikacin, bupivacaine, fentanyl and Kounis syndrome

“…[1] In the very interesting paper published in this Journal, [2] a 59-year-old healthy male developed rashes in his upper limb, chest, and abdomen followed by breathlessness, tachycardia, severe hypotension, and cardiovascular collapse 2 min after intravenous injection of 1 g amikacin. [7] Intravenous fentanyl, which is a potent, synthetic opioid analgesic used extensively for anesthesia and analgesia has been also incriminated for inducing allergic reactions and anaphylaxis. The authors correctly attributed the anaphylactic shock to amikacin administration and treated the patient accordingly with excellent results.…”