Anaphylatic shock

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  • 1. Anaphylactic Shock in General Anesthesia
  • 2. General Data 16 y/o , Indian Female , 40 kgw No underlying comorbid Hx of allergy to ? Antibiotics – generalized rashes No history of previous surgery
  • 3. General Data Diagnosed to have: frontoethmoidal mucocele Planned for: FESS Before op: requested by surgeon for controlled hypotension, propofol infusion for maintenance and tranexemic acid prophylaxis General anesthesia was done . Induction with Fentanyl 80 ug , propofol 100mg, atracurium 30mg , morphine 3mg
  • 4. General Data Maintenance: isoflurane 1.0 propofol infusion –running at 30-50mg/H atracurium 10mg (stat dose at 30 and 1 H after induction) - in 1st hour of op: Bp: 90-100/50-60, MAP: 60-70 no episode of hypotension HR: 90-110 ET CO2 : 32-40 SpO2 : 99-100
  • 5. General Data At 1H of op: 1g tranexemic acid given (was put in 300cc NS infusion) After 10min: noted ETCO2 wave showed bronchospasm, no desaturation -increase isoflurane flow BP: 60/40, reduce isoflurane, bronchospasm resolved but BP further decrease despite ephedrine 6mg x2 given
  • 6. General Data Pulse : weak ECG: sinus tachycardia HR 120-130 BP drop to 43/24 (MAP 30) SpO2 : 99% wave form: pulsus paradoxus EtCO2: waveform normal 32-34 Given IV adrenaline 1:10,000 x1ml twice
  • 7. General Data Subsequently after few minutes Sp O2: waveform normal 99% BP: pick up 60/40- 80/60 HR : 100-110 Operation finished after 1H 15min, patient extubated well, discharged to general ward
  • 8. What Happened ? Anaphylactic shock secondary to Tranexemic acid
  • 9. Anaphylaxis during anesthesia Definition Anaphylaxis : rapid, generalized immunologically mediated events involving an antigen-specific IgE-mediated mechanism that occur after exposure to foreign substances in previously sensitized persons
  • 10. Anaphylaxis during anesthesia The incidence of anaphylaxis in GA is about 1:5000 to 1: 20000 and with a mortality rate of up to 6% Mechanism : 1.Specific IgE cross-linked by allergen (drug) 2. Complement activation by specific IgG or IgM binding to antigen (drug) 3. Direct complement activation by way of the alternate pathway 4. Direct activation of mast cells or basophils
  • 11. CAUSES OF ANAPHYLAXIS AND ANAPHYLACTOID REACTIONS DURING ANESTHESIA Causes Rate of Reaction (%) Muscle relaxants 61.6 Latex 16.6 Antibiotics 8.3 Hypnotics 5.1 Colloids 3.1 Opioids 2.7 Other (aprotinin, ethylene oxide, local anesthetics) 2.6 Data from French survey by Perioperative Anaphylactoid Reactions Study Group; 1648 patients, July 1994 to December 1996.
  • 12. Latex High-risk groups: 1.Health-care workers or other occupational exposure 2.Multiple surgical procedures 3.Atopic patients 4.Fruit allergy
  • 13. Colloids Prior drug allergy and male Gelatins(0.34%) and dextrans(0.27%) more likely than albumin(0.1%) and hetastarch(0.06%)
  • 14. Pathophysiology Multiple organ systems are affected Initial exposure to antigen → IgE production and bind to mast cells and basophils Reexposure → release of mediators from mast cells and basophils
  • 15. Management
  • 16. From FDA reports: Tranexamic acid and Shock anaphylactic This is a study of Shock - anaphylactic (Anaphylaxis) among people who take Tranexamic acid. The study analyzes: the time on Tranexamic acid when people have Shock - anaphylactic, age of these people, the severity of Shock - anaphylactic, how they recovered, and common conditions and drugs used besides Tranexamic acid. In total 1,505 Tranexamic acid users are studied. The study is created by eHealthMe based on reports from FDA and is updated regularly.
  • 17. From FDA reports: Tranexamic acid and Shock anaphylactic Tranexamic acid has active ingredients of tranexamic acid. Commonly reported side effects of Tranexamic acid include haemoglobin decreased, fever, rectal haemorrhage, melaena, vaginal haemorrhage. Shock - anaphylactic has been reported by people with multiple sclerosis, asthma, blood pressure management, high blood pressure, premedication.
  • 18. From FDA reports: Tranexamic acid and Shock anaphylactic 1,505 people reported to have side effects when taking Tranexamic acid. Among them, 19 people (1.26%) have Shock Anaphylactic.
  • 19. From FDA reports: Tranexamic acid and Shock anaphylactic
  • 20. From FDA reports: Tranexamic acid and Shock anaphylactic
  • 21. Pulsus paradoxus
  • 22. Pulsus paradoxus During inspiration, the right ventricle distends due to increased venous return, the interventricular septum bulges into the left ventricle reducing its size (reversed Bernheim effect), and increased pooling on blood in the expanded lungs decreases return to the left ventricle, decreasing the stroke volume of the left ventricle. Additionally, negative intrathoracic pressure during inspiration is transmitted to the aorta. The relatively higher negative pressure in the pulmonary circulation compared to the left atrium in patients with pericardial pathology causes back flow of blood from the left atrium into the pulmonary veins during inspiration.[2] Therefore, during inspiration the fall in the left ventricular stroke volume is reflected as a fall in the systolic blood pressure. The converse is true for expiration. During quiet respiration, the changes in the intrathoracic pressures and blood pressure are minor. The accepted upper limit for fall in systolic blood pressure with inspiration is 10 mmHg.
  • 23. Pulsus paradoxus Cardiac causes 1. Cardiac tamponade 2. Pericardial effusion 3. Constrictive pericarditis 4. Restrictive cardiomyopathy[4] 5. Pulmonary embolism 6. Acute myocardial infarction 7. Cardiogenic shock Extracardiac pulmonary causes 1. Bronchial asthma 2. Tension pneumothorax Extracardiac non-pulmonary causes 1. Anaphylactic shock 2. Volvulus of the stomach[6] 3. Diaphragmatic hernia[6] 4. Superior vena cava obstruction[4] 5. Extreme obesity
  • 24. Thanks for your Attention !!