1. Peter Sherren

2. NOT EVERY SWOLLEN FACE IS
ANAPHYLAXIS

3.  In 1990, the Association of Anaesthetists of Great Britain and
Ireland (AAGBI) published its first report on suspected
anaphylactic reactions associated with anaesthesia.
 The reported suspected that, between 1995-2001, anaphylactic
reactions related to anaesthesia in the UK averaged 55 per year,
compared with 319 for all drugs1.
 10% of anaesthetic reports were of fatalities compared with
3.7% for all drugs reported1.
 The understandable concentration on anaphylaxis within
anaesthesia means that the knowledge of differential diagnoses
and therapeutic options may be limited.

4.  66 yr-old Afro-Caribbean lady  MP V?
 Htn, DM, IHD and PPM
 05.00 Sudden onset tongue
swelling and DIB
 Called to DGH ED 06.15
 Dramatic angioedema+,
drooling++, stridor, poor
vocalisation, agitated, SpO2
~92% FiO2 0.85 FM. CVS stable

5.  Unexpected complication of treatment.
 Unresponsive to steroids/anti-histamines/adrenaline.
 ODP transported difficult airway trolley to resus.
 Surgical Spr not happy/competent to perform emergency awake
trache.
 18g cannula cricothyroidotomy performed pre-induction
uneventfully.
 RSI, Grade III/IV (oedematous, distorted anatomy) view with McCoy.
 GEB sited 3rd pass.
 Unable to pass 7.0 coett, 6.0 passed with difficulty, minimal leak with
no cuff deflated.
 No issues ventilating.
 Progression of angioedema post intubation.
 10 day ICU admission, discharged to ward neurologically intact with
trache insitu.

6.  Out of hours communication/mobilisation of staff
and equipment outside of theatres.
 Familiarity with, and applied use of equipment on a
well-stocked (theatre) difficult airway trolley.
 Flexible use of DAS algorithm.

7.  Inadequate difficult airway trolley in ED.
 Rail-roading size 6.0 coett over 15F bougie is
fiddly. Any smaller would have required a
CHANGE of bougie for a 10F.
 Retrospectively, the needle cricothyroidotomy was
unnecessary, exposing already difficult airway to
potential trauma.
 General surgical training inadequate?

8.  Causes of angioneurotic oedema
 Idiopathic- large proportion.
 Mast cell related/anaphylaxis.
 Hereditory (HAE) I and II- C1 inhibitor deficiency or dysfunction.
 Acquired- immunosuppression and lymphoproliferative disorders.
 Drug related- Aspirin/NSAIDS, ACE, opiates, abx.
 ACE inhibitors related angioneurotic oedema2,3:
 Now most common exogenous cause of angioedema seen.
 Can occur any time from initiation through to 10 years into treatment.
 0.1-0.5% of those receiving the drug.
 Usually has no associated urticaria.
 Due to increased bradykinin levels because kinin degradation is inhibited.
 Can cause dramatic swelling of tongue, pharynx, or larynx- Secure airway
early.
 Deaths related to AIRWAY, no reported deaths from primary CVS collapse.
 Some response to Adrenaline and minimal to steroids and anti-histamines.

10.  In angioneurotic oedema (like burns):
• Use of size 10F bougie
• Use of uncut COETT
• Range of sizes of COETT ready for use
 Potential unique use of the Melker vs other large
bore cricothyroidotomy kit
 Improvement/standardisation of difficult airway
trolley in ED

11.  Choice of large bore cricothyroidotomy kit?
• CUFFED seldinger vs PCK vs Quicktrach II
 Place for selected pre-emptive cannula
cricothyroidotomy and later use of Melker?

12. 1. AAGBI Working party. SUSPECTED ANAPHYLACTIC
REACTIONS ASSOCIATED WITH ANAESTHESIA.
AAGBI Revised Edition 2003. www.aagbi.org
2. Adebayo PB, Alebiosu OC. ACE-I induced angioedema: a
case report and review of literature. Cases J. 2009 Jul
27;2:7181.
3. Cupido C, Rayner B. Life-threatening angio-oedema and
death associated with the ACE inhibitor enalapril. S Afr
Med J. 2007 Apr;97(4):244-5