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• W4255355898 abstract "Muscle relaxants (MR) are responsible for more than 80% of anaphylactic shock during anesthesia (1). Allergic reactions are less frequent in children than in adults (2). Cisatracurium, a new nondepolarizing MR, induces less allergic reaction than other MR (3). We describe a case of anaphylactic reaction with cisatracurium in a child. Case Report A 10-yr-old male (body weight 32 kg), ASA physical status III, was scheduled for decompressive craniectomy because of intracranial hypertension. His medical history included asthma, left thoracotomy related to surgical correction of patent ductus arteriosus, meningitis, ectopic testicles, and psychomotor defect. His previous nine surgical procedures were performed using vecuronium without any adverse effect. The patient had no daily medication and was not known to be allergic to any medications. Preoperative medication, given orally 30 min before induction, was clorazepate dipotassic (15 mg). In the operating room, standard monitors were applied. The patient’s blood pressure (BP) was 134/74 mm Hg, with a sinus rhythm and heart rate of 102 bpm. Anesthesia was induced with sevoflurane 8%, nitrous oxide (N2O) 50% in oxygen, and sufentanil (25 μg), with cisatracurium (3.2 mg) administered for tracheal intubation. There was no significant change in heart rate or BP. After tracheal intubation, anesthesia was maintained with desflurane (5%), N2O 50% in oxygen. An IV line filled with hydroxyethyl starch (0.6, 2 000 000, Elohes®, Fresenius) was connected to the patient, but the infusion was not yet started. Ten minutes after induction, BP decreased to 60/30 mm Hg, with a moderate sinus tachycardia (110 bpm). A generalized erythema was observed, and breath sounds were decreased bilaterally with wheezing. The diagnosis of anaphylactic shock was made. Antibiotic had not yet been given to the patient. Administration of desflurane and N2O was discontinued and preparation for the surgery was stopped. The IV line filled with Elohes® was disconnected from the patient; its infusion had not yet begun at the time of the anaphylactic reaction. BP increased to 100/40 mm Hg after IV administration of 0.5 mg of epinephrine, which was repeated, and an epinephrine infusion at 0.5 mg · h−1 was started. An albumin infusion was also started at 750 mL · h−1, and the patient received 500 mg of hydrocortisone. BP stabilized to 90/50 mm Hg. Arterial oxygen saturation, as measured by pulse oximetry, was 99%. Because of the hemodynamic instability, the surgical procedure was cancelled. The patient was transported to the neurosurgical intensive care unit, sedated, and mechanically ventilated for 12 h. He was progressively weaned from epinephrine, which was definitively discontinued 24 h after the onset of anaphylactic shock. The patient made a good recovery. Blood samples, immediately drawn after the clinical diagnosis of anaphylactic shock, showed an increased in tryptase concentration to 19 μg · L−1 (normal value <2 μg · L−1) and an increase in histamine concentration to 86 nmol · L−1 (expected value <11 nmol · L−1). Standard allergy testing for cisatracurium, sufentanil, Elohes® and other muscle relaxants (MRs) was performed by the intradermal skin reaction technique. They gave positive results for cisatracurium, Elohes®, and also for other MR (Table 1).Table 1: Intradermal Skin Reactions, Presented as the Diameter of the Papula (mm)Discussion Cisatracurium is a new nondepolarizing MR that is less likely than other MRs to cause histamine release or to inhibit the enzymes that degrade histamine (4). We have described a case of anaphylactic shock after the administration of cisatracurium in a child. Cisatracurium was considered to be the causative drug because the hemodynamic and respiratory manifestations occurred immediately after injection (5,6). Other possible diagnoses considered were latex, Elohes®, and sufentanil allergy. Latex allergy was considered, as latex has been implicated in 17% of episodes of intraoperative anaphylaxis and is the more frequent etiology noted in children (1). However, a latex test was performed after hospital discharge and was negative. There have been severe allergic reaction to hydroxyethyl starch, including Elohes®, but the incidence of anaphylactic reaction to hydroxyethyl starch is very small (7). The incidence of anaphylactic reactions to Elohes® has been estimated to be 0.047% in France (1). In the case of our patient, the IV line filled with Elohes® was connected to the patient, but the infusion was not yet started when the anaphylactic reaction occurred. Therefore, it is unlikely that Elohes® was responsible for the allergic reaction. We cannot eliminate the possibility that sufentanil may have caused the anaphylactic reaction observed in our patient (Table 1). However, we found no report of allergy after sufentanil in the literature. Thus, if sufentanil had been involved, this would be the first case of its having played a role in anaphylaxis. However, the result of the intradermal skin test to sufentanil was considered as a negative result by the pediatric allergologist who performed the test because the diameter of the papula remained unchanged from 1:1000 to 1:10 dilutions (Table 1). The realization and interpretation of the intradermal skin test are difficult in children, because they are often afraid of the puncture and therefore may be combative; this was the case in our patient. Therefore, it may be that some intradermal injections were not adequately performed, which may have induced false negative results at intermediate dilutions, as was the case in our patient for Elohes®, atracurium, pancuronium, and rocuronium at 1:100 dilution (Table 1). During an episode of suspected anaphylaxis, a confirmation of the diagnosis should be sought. In our patient we found an increase in blood histamine and tryptase concentrations, indicating a mast-cell-mediated process. Furthermore the intradermal skin reaction made after the discharge of the patient found a positive result for cisatracurium and other muscle relaxants (Table 1). We have presented the first case of anaphylactic reaction to cisatracurium in a child. The purpose of this report is to increase the anesthesiologist’s awareness of the allergic potential of this drug. The authors would like to thank Dr. D. J. Baker, M Phil DM FRCA, for kindly reviewing the manuscript." @default.
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• W4255355898 title "Severe Anaphylactic Reaction to Cisatracurium in a Child" @default.
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• W4255355898 doi "https://doi.org/10.1213/00000539-200103000-00018" @default.
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