Intraoperative Anaphylactic Reaction: Is it the Floseal?

Abstract

When hemodynamic or respiratory instability occurs intraoperatively, the inciting event must be determined so that a therapeutic plan can be provided to ensure patient safety. Although generally uncommon, one cause of cardiorespiratory instability is anaphylactic reactions. During anesthetic care, these most commonly involve neuromuscular blocking agents, antibiotics, or latex. Floseal is a topical hemostatic agent that is frequently used during orthopedic surgical procedures to augment local coagulation function and limit intraoperative blood loss. As these products are derived from human thrombin, animal collagen, and animal gelatin, allergic phenomenon may occur following their administration. We present 2 pediatric patients undergoing posterior spinal fusion who developed intraoperative hemodynamic and respiratory instability following use of the topical hemostatic agent, Floseal. Previous reports of such reactions are reviewed, and the perioperative care of patients with intraoperative anaphylaxis is discussed.

Engineering a naturally derived hemostatic sealant for sealing internal organs

“…Therefore, several hemostatic hydrogels were engineered with different coagulating agents to minimize the blood loss from the wound site [ 35 ]. For example, Kaolin-based QuikClot adhesive bandage [ 36 ] and gelatin-thrombin-based injectable Floseal [ 37 ] have already been introduced to market. Inorganic nanostructure (e.g., laponite) with a large negative surface charge, was also used to improve the hemostatic efficiency of the hydrogels [ [38] , [39] , [40] , [41] ].…”

Review of topical gelatin‐based haemostatic agents; an insidious culprit of intraoperative anaphylaxis?

“…Anaphylaxis is an IgE-mediated type I hypersensitivity reaction with systemic release of pro-inflammatory mediators including histamine, tryptase, cytokines and prostaglandins. However, authors note that tryptase levels are not 100% sensitive, 34 with plasma levels peaking at 60-120 min post event, 22 allowing for insignificant results if taken prematurely or late, and IgE sensitivity ranging from 60% to 95%. 35 It typically occurs on secondary exposure with a specific antigen, however, has been reported to occur on primary exposure due to cross reactivity among many products.…”

“…Anaphylactoid reactions are clinically indistinguishable from anaphylaxis with similar symptomatology without the elevation in tryptase, IgE or skin prick testing. 22 Under a general anaesthesia in a surgical procedure, cardiovascular collapse may be the only sign anaphylaxis is occurring, and causes need be investigated. It is reported an intravenous infusion of gelatin in a colloid based fluid will take approximately 15-30 min to manifest a reaction, whereas the identified cases in this review, topical application of gelatin haemostats occurred within minutes.…”

“…It is reported an intravenous infusion of gelatin in a colloid based fluid will take approximately 15-30 min to manifest a reaction, whereas the identified cases in this review, topical application of gelatin haemostats occurred within minutes. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Causes of cardiovascular collapse are outside the scope of this article; however pertinent to this article is the adverse effect of haemostat emboli. The incidence of venous thromboembolism secondary to gelatin haemostats in tumour removal ranges from 4.7% to 8.4%, with patients receiving ≥10 mL of gelatin haemostat at a higher risk.…”

“…2 The first gelatin-based haemostat was used in 1940s, 3 and has been a theatre staple with ease of use, accessibility and effectiveness. However, there have been rare reports of hypersensitivity reactions [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] (Table 1).…”