Anaphylactic reactions after cisatracurium administration in two patients -a report of two cases-
A 70-year-old male (weight, 53.2 kg; height, 155 cm; American Society of Anesthesiologists physical status classification I) was anesthetized for total gastrectomy. The patient had a previous experience with general anesthesia in 1978 for an operation for gastric perforation but information about the anesthetic technique was not available. His past medical history and family history were insignificant.\nHe received no premedication other than cefotetan 1,000 mg IV, which was administered 20 minutes before his arrival without apparent adverse effects. Full monitoring was established and midazolam 2 mg and lidocaine 40 mg were administered. General anesthesia was induced with TCI (Asan Pump, version 2.0, Bionet Co., Ltd., Seoul, Republic of Korea) of microemulsion propofol 1.2 µg/ml (Aquafol™, Daewon Pharmaceutical Co., Ltd., Seoul, Korea) and remifentanil 3 ng/ml, followed by cisatracurium 12 mg. Approximately 1-2 minutes after induction, the non-invasive blood pressure was unmeasurable and mask-valve ventilation of his lungs was difficult with a SaO2 decrease from 99 to 85%. The patient was intubated immediately and assumed the head-down position. At this point, the measured non-invasive blood pressure was 45/20 mmHg and the heart rate was 70 beats/min. The patient was ventilated with 100% oxygen with a tidal volume of 450 ml and a respiratory rate of 14 breaths/min; the peak airway pressure was 30 cmH2O. On auscultation, wheezing was apparent in both lungs. Repeated doses of epinephrine 20 µg up to a total dose of 40 µg were administered and a continuous infusion of epinephrine was started at 0.1 µg /kg/min. A 16 G catheter was inserted and colloid 500 ml was loaded. An arterial catheter was placed in the right radial artery. The arterial blood pressure increased to 146/90 mmHg and the treatment for bronchospasm with a salbutamol inhaler and hydrocortisone 100 mg IV was started promptly. The hemodynamics stabilized and the peak airway pressure dropped from 30 to 20 cmH2O. The epinephrine infusion was tapered off and eventually discontinued. After monitoring the patient closely for an hour in the operating room, the neuromuscular blockade was reversed with glycopyrrorate 0.4 mg and pyridostigmine 15 mg. The patient was awake and extubated without incident. A follow-up chest X-ray was normal. The patient was transferred to the post anesthesia care unit and had an uneventful recovery.\nAbout 3 weeks later, the patient underwent allergy skin testing, including the skin prick test and the intradermal test for all perioperatively used medicines and other NMBAs. The patient reacted to cisatracurium at a 1 : 100 dilution and showed an equivocal reaction to rocuronium at a 1 : 100 dilution (). The patient returned for surgery a month after the event and underwent uneventful anesthesia with vecuronium.