Anaphylactic reactions after cisatracurium administration in two patients -a report of two cases-
A 52-year-old male (weight, 63 kg; height, 167 cm, American Society of Anesthesiologists physical status classification I) was scheduled for laparoscopic low anterior resection for rectal cancer. He had no significant past medical history and no previous experience of general anesthesia. His family history included his mother's asthma.\nThe patient arrived at the operating room with no premedication. Cefotetan 1,000 mg IV was administered 20 minutes before arrival with no apparent adverse effects. His blood pressure, heart rate, and SpO2 were 140/80 mmHg, 60 beats/min, and 100%, respectively. After standard monitors were applied, midazolam 2 mg and lidocaine 20 mg were administered. Induction was started with a target effect-site concentration-controlled infusion (TCI; Asan Pump, version 2.0, Bionet Co., Ltd., Seoul, Korea) of propofol 2 µg/ml and remifentanil 3 ng/ml, followed by a bolus administration of cisatracurium 12 mg. Within a minute, mask-valve ventilation became difficult with pulse oximetry decreasing to 90%. His trachea was intubated immediately and ventilated with 100% oxygen. At this point, the peak airway pressure exceeded 30 cmH2O with a tidal volume of 550 ml and a respiratory rate of 12 breaths/min. The breathing sound in both lungs was decreased and wheezing was apparent on auscultation. Signs of cardiovascular collapse were also present: the blood pressure was 60/40 mmHg and there was a slight increase in the heart rate from 65 to 80 beats/min. Cutaneous reactions such as rash or urticaria were absent. A clinical diagnosis of anaphylactic shock was made. The patient was promptly treated with a 500 ml fluid bolus of lactated Ringer's solution and repeated doses of epinephrine10 µg up to a total dose of 50 µg. Arterial and 16 G venous catheters were placed and 500 ml of colloid was loaded. A continuous infusion of epinephrine was started (0.05 µg/kg/min). The blood pressure increased to 125/75 mmHg. Treatment for the bronchospasm was initiated by administering inhaled salbutamol through the endotracheal tube and hydrocortisone 100 mg IV. An hour after the event, the epinephrine infusion was slowly discontinued as the hemodynamics stabilized. The blood pressure and heart rate after epinephrine infusion discontinuation were 135/90 mmHg and 90 beats/min, respectively. The peak airway pressure decreased to 26 cmHg with the same ventilator setting. Wheezing was no longer present on auscultation. The surgery was cancelled and the patient was transported to the surgical intensive care unit with his trachea remaining intubated. One hour after arrival, the patient was awake and extubated without incident. His postoperative chest X-ray was normal.\nThree days later, the patient underwent allergy testing with the skin prick test for common allergens (latex included), an intradermal test for all perioperatively used drugs, and the metacholine bronchial provocation test. Other NMBAs such as succinylcholine, vecuronium, and rocuronium were included in the intradermal test drug panel. Skin testing revealed a positive reaction to cisatracurium at a 1 : 100 dilution (). All other medicines were negative. The patient also reacted positively in the metacholine bronchial provocation test.\nA week after the event, the patient was pretreated with methylprednisolone and fluticasone/salmeterol inhaler and returned for the scheduled surgery. Vecuronium was used instead of cisatracurium. The operation was uneventful.