Use of alpha‐agonists for management of anaphylaxis occurring under anaesthesia: case studies and review

Abstract

SummaryAnaphylaxis is an uncommon but serious complication of anaesthesia. Most current guidelines for the management of anaphylaxis list only epinephrine as a vasopressor to use in the event of cardiovascular collapse. We present two cases of anaphylaxis under anaesthesia where return of spontaneous circulation was refractory to epinephrine, but occurred following the administration of the alpha-agonist metaraminol. Potential advantages and disadvantages of using epinephrine in this setting, the role of alpha-agonists and some potential mechanisms accounting for their role in successful management are reviewed.

Part 12: Cardiac Arrest in Special Situations

“…[77][78][79] Other small case series described successful results with administration of alternative ␣-agonists such as norepinephrine, 80 methoxamine, 81,82 and metaraminol. [83][84][85] Alternative vasoactive drugs (vasopressin, norepinephrine, methoxamine, and metaraminol) may be considered in cardiac arrest secondary to anaphylaxis that does not respond to epinephrine (Class IIb, LOE C). No randomized controlled trials have evaluated epinephrine versus the use of alternative vasoactive drugs for cardiac arrest due to anaphylaxis.…”

Part 8: Advanced Life Support

“…480,481 A few small case series (LOE 4) have described promising initial findings with ␣-agonists such as norepinephrine, 482 methoxamine, 483 terlipressin, 484 and metaraminol. [485][486][487] A few small case reports (LOE 4) of cardiac arrest suggest cardiopulmonary bypass 488,489 or mechanical support of circulation 490 may be helpful in the setting of anaphylaxis.…”

“…Several case reports (LOE 4) document the use of a variety of interventions for cardiac arrest caused by anaphylaxis: 6 case reports support high dose ␣-1 receptor agonists: metaraminol, 485,486 methoxamine, 483,487 and norepinephrine. 482 Other case reports document the use of terlipressin, 484 vasopression, 481 steroids and antihistamines, 491 and cardiopulmonary bypass.…”

Vasopressor and Inotrope Use in Canadian Emergency Departments: Evidence Based Consensus Guidelines

“…[88][89][90] There are multiple case reports describing the use of vasopressin, norepinephrine and methylene blue in patients with anaphylaxis refractory to epinephrine. [91][92][93][94][95][96][97][98][99][100][101] Consensus guidelines recommend the use of an epinephrine infusion if a vasopressor infusion is required for patients with anaphylactic shock.…”