Persistent anaphylactic reaction after induction with thiopentone and cisatracurium

Abstract

A 6-year-old boy presented for surgery for phimosis. The anaesthetic technique included intravenous induction with thiopentone and neuromuscular blockade with cisatracurium. Severe persistent bronchospasm and central cyanosis followed the administration of these drugs. A continuous i.v. infusion of epinephrine at 0.2 microg. kg(-1) x min(-1) was necessary to break the severe refractory bronchial hyperresponsiveness. There was no previous exposure to anaesthetic drugs and no definite family history of allergy. Through increased serum eosinophil cationic protein, tryptase and histamine levels and IgE levels specific to cisatracurium, we demonstrated an IgE-mediated anaphylactic reaction to cisatracurium in the child's first exposure to this new neuromuscular blocking agent. Anaphylactic reactions to new anaesthetic drugs may be challenging to recognize and treat during general anaesthesia in children. The pathogenesis, diagnosis and management of life threatening persistent allergic reactions to intravenous anaesthetics are discussed.

Allergic Reactions in the Perioperative Period in Children

“…In children, the most frequent symptoms were respiratory (coughing, wheezing, bronchospasms, respiratory insufficiency), contrary to the data reported in adults, where the frequency was equivalent to only 40% in perioperative anaphylactic reactions [48]. The observable difference in respiratory symptoms is due, to patient atopy (where coexistent allergic asthma could be associated), which was observable in some cases and could undervalue the risks of the patient [20,21]. Likewise, emphasizing latex as a volatile allergen could favor respiratory signs, such as bronchospasms.…”

“…(Table 2) [17,18,20,23,24]. Also, when the reactions were related to latex, most reports were carried out using an adequate allergological evaluation [12,28,29,[32][33][34]36,37,[39][40][41]74].…”

“…Among the reported cases on anaphylaxis, the time is the key, administration should be investigated, whether intravenous or topical, the time of onset of symptoms (with an average of 3 minutes from administration to the appearance of clinical signs) [17][18][19][20]22,23,26,73]. A lack of mucocutaneous signs in five severe reactions was observed [12,14,16,20,36]. In the French Society's study, bradycardia in 14% of the cases was also reported, but it wasn't specified whether it was related to circulatory collapse and/or secondary hypoxia [69].…”

Anaphylactic reactions after cisatracurium administration in two patients -a report of two cases-

“…Early clinical reports suggested that cisatracurium has negligible histamine-releasing potential and is a less potent trigger of allergic reactions than other NMBAs [3]. However, since 1995, several cases of cisatracurium-induced anaphylactic reactions with severe symptoms of cardiovascular collapse and bronchospasm have been reported [4-7]. …”

“…Cisatracurium, a relatively new NMBA, is a stereoisomer of atracurium, which does not induce apparent histamine release upon a bolus administration and causes fewer allergic reactions than other NMBAs [3]. However, several cases of anaphylactic reactions of varying severity to cisatracurium have been reported [4-7]. Two cases of severe anaphylactic reactions after cisatracurium administration are reported here.…”