BP 25/-

 

75 yo female for redo fem-pop bypass

Past History:  well;  activity limited by R leg claudication       

            no overt cardio resp disease

            "indigestion" – epigastric  discomfort. No reflux

            previous anaesthetics:        laminectomy  (2 levels)

            PVD:   2 FPB's over past 8yrs.

            No known allergies 

On examination:     64 kg  166cm, 130/70, dual rhythm, no bruits,  chest – NAD

Medication:    aspirin

                     ranitidine / esomeprazole  prn

Monitoring:  IV with hot line.;  arterial line;  ECG;  SaO2;  gas monitoring

Warming: Bair Hugger;

 

Induction:     IV - dextran 40 (promit) had been running for about 15min

                    propofol 30 mg, fentanyl 40 mcg, cisatracurium 10 mg

                    4LMA proseal inserted at 1.5 min

                    BP stable until about 2 min mark then fell to about 60 mmHg.

                    Metaraminol 0.5 mg given

BP fell to 40mmHg:  Metaraminol 2 mg given   ECG unchanged ( rate 80 in sinus rhythm)   SaO2 97%

                        Intubated

                        BP fell to 25mmHg:  no peripheral pulses palpable so CPR

                              commenced

 

PRESUMPTIVE DIAGNOSIS:  ANAPHYLAXIS

 

Treatment:   adrenaline 0.5mg  - BP rose to 35mmhg

                    then 1mg bolus -  BP to 50mmhg    CPR ceased.

Repeat boluses of adrenalin 1 to 2 mg every few minutes brought BP to 70  where it stabilised with continued adrenalin boluses.  Total of 12mg adrenalin was given as boluses.

            CVC inserted

            Adrenalin infusion commenced @ 10ug/min to maintain BP 70

            Initially stable, then developed tachycardia  of 180/min with runs of VT.

            So adrenalin replaced with noradrenalin infusion with return to SR 90/min

            and BP stable at about 70-80 systolic.

            Stable for 15min, then transferred to ICU

 

Blood taken for tryptase level

 

Husband notified.

 

Discharged from ICU next day -100% recovery

 

Tryptase  72 mcg/L  (normal less than 13.5)

 

 Skin testing  (5 weeks later)  :

morphine  +ve control         saline -ve control     propofol 1/100

fentanyl 1/50                         cisatracurium 1/10,000       rocuronium 1/10,000

sux  1/1000

 

POSITIVE for cisatracurium (and incidentally rocuronium).

 

 

Comment 1

That is a lot of adrenaine required in a short space of time!

 

Comment / Question 2

Would it have been worthwhile to get an adrenaline infusion started earlier?

How do you make up such an infusion and at what rate would you start it in this situation?

 

Comment 3

If this patient required a relaxant GA at a later time, which drug would you choose?