Abstract
Purpose: To report the use of vasopressin to treat a patient who, after failing to respond to volume expansion and epinephrine administration, experienced an anaphylactic reaction to rocuronium.
Clinical features: A 17-yr-old female was scheduled to undergo transnasal, transsphenoidal resection of a pituitary tumour. Shortly after induction of general anesthesia, for which rocuronium 50 mgiv was administered to facilitate tracheal intubation, the patient developed severe hypotension and diffuse erythema. This severe,allergic response was refractory to the administration of intravenous fluids, epinephrine, and phenylephrine. However, arginine vasopressin, administered intravenously as a bolus of two units, followed by an infusion of 2 U·hr−1, rapidly corrected the hemodynamic instability. Her recovery from this episode was uneventful, but surgery was cancelled. Skin testing, performed six weeks later, was positive for rocuronium and negative for cisatracurium and latex, as well as all other medications administered. Eight weeks later, the surgical procedure was performed, uneventfully, using cisatracurium as the muscle relaxant.
Conclusions: Vasopressin may be effective in the resuscitation of anesthetized patients, with hemodynamic instability associated with anaphylaxis resistant to epinephrine and alpha-agonists.
Résumé
Objectif: Rendre compte de l’utilisation de vasopressine pour traiter une patiente qui a présenté une réaction anaphylactique au rocuronium, réfractaire à l’expansion volumique ou à l’administration d’épinéphrine.
Éléments cliniques: Une résection trans-nasale, trans-sphénoïdale d’une tumeur de l’hypophyse était prévue chez une jeune femme de 17 ans. Peu après l’induction de l’anesthésie générale comportant l’administration de 50 mg iv de rocuronium afin de faciliter l’intubation trachéale, la patiente a développé une hypotension grave ainsi qu’un érythème diffus. Cette réaction allergique grave s’est avérée réfractaire à l’administration de liquides intraveineux, d’épinéphrine et de phényléphrine. Toutefois un bolus de deux unités d’arginine-vasopressine administrée en intraveineuse, suivi par une perfusion de 2 U·hr−1, a permis de corriger rapidement l’instabilité hémodynamique. Il n’y a pas eu d’événement durant le rétablissement de la patiente, mais la chirurgie a été annulée. Un test cutané effectué six semaines plus tard a montré des résultats positifs pour le rocuronium et négatifs pour le cisatracurium et le latex ainsi que pour les autres médicaments administrés. Huit semaines plus tard, l’intervention chirurgicale a eu lieu, sans complications, en utilisant du cisatracurium comme curare.
Conclusions: La vasopressine peut être efficace pour réanimer les patients anesthésiés présentant une instabilité hémodynamique associée à une anaphylaxie résistante à l’épinéphrine et aux alphaagonistes.
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Meng, L., Williams, E.L. Case report: Treatment of rocuronium-induced anaphylactic shock with vasopressin. Can J Anesth 55, 437–440 (2008). https://doi.org/10.1007/BF03016310
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DOI: https://doi.org/10.1007/BF03016310