208 Pentothal anaphylaxis
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PROT‘AMINE INDUCED SHOCK:EVIDENCE OF MAST CELL INVOLVEMENT JA Esplin,GL Sussman,IB Schwartz, Toronto,Ontario A 75 year old male underwent elective abdominal aortic aneurysm repair.Protamine sulfate 25m9/IV was given to reverse heparinisation.There was no prior history of exposure to Protamine. Within minutes he developed tachycardia(75S150 per minute),hypotension(l20/60~50 mm/Hg systolic) and non-cardiogenic pulmonary edema(PA wedge lOnung/Hg(nl 5-13mm/Hg),cardiac output 4.4 L/min, systolic vascular resistance 1264(nl 1130f178). There was progression of signs with evidence of severe hypoxia and shock lung(PAO2 SOmm/Hg on F102 1.00 and PEEP 12.5cm/H20)and lactic acid- osis(7.2annol/L(nl 3mmol/L).Massive capillary leakage was documented with a decrease of albumin to ll(n1 35-50).Urticaria also occurred. Workup excluded other causes(negative for D.I.C., sepsis,transfusion reaction,cardiogenic sources, and hypovolemia).There was no evidence of comp- lement activation.Complete reversal of all signs and symptoms occurred within 14 hr.Subs.equent workup with Protamine prick and intradermal skin tests were negative.Prick skin tests with fish and salmon were also negative-serial tryp- tase activity was taken at the time and detected mild but noteworthy elevation(from 2.535.0 rig/ml at 5 hr.with a return to baseline at 9 hr).The peak level could have been missed,with the first post shock specimen drawn at 5 hr;at least after one complete half-life of decline.We conclude: 1)Protamine can produce non-cardiogenic pulmon- ary edema.2)Elevated tryptase with serial spec- imens suggest mast cell participation in this reaction.3)There is no evidence that this is IgE me_dia~ed,or..crass~reac~.s..~ftb fish or salmon. enrerE, Malaga, Spain, True allergic reactions to lucal anesthetics can be under 1% of tutal adverse effects,They have chenical struc- tures in cummun and others different, Based un patch test results it seems that there is nut crussreactlvity arnung both groups, We present a 70 y,o, patient whu experienced five episudes of hyputensiun after using tetracain fur uretral dilatations, R controlled observation uf the patient introducing a catheter in the uretra with tetracain produced a severe hyputhensiun with generalised erythema and pruritus, Tutal IgE was 900 IU ml and a MST was develupped coupling nuvocaine tu HSA. The need of use uf local anesthetics justified the trial uf a compound of the amido group, Skin tests with incremental cuncentrations of lidocaine frun 0,2 till 20 mgr ml were negative, After injecting subcutaneously lml (50 mgrl a generalised erythena with pruritus appeared that was cuntrulled with antihistamines and adrenaline, After une year the patient was challenged again with lidocalne. Skintest with lidutaine were negative and an injectiun of 50 mgr in the forearm produced local erythema and pruritus in all the region, The procedure was repeated after 15 days giving the same reaction, The same amount was tested in five negative contruls wwith good tolerance. This case can be considered as having sensitivty tu both esther and amidu local anesthetics, The IgE to a RAST of nuvucaine-HSA was negative , Plthuugh the antigenic determinants and the inmunological mechanisms are not well known, in this case a common inmunolugical pathugenesis can produce sensitivty to both groups of anesthetics, PENTOTHAL ANAPHYLAXIS. A, Cheema, M.D., G. L. Sussman, M.D., 2. Janoelewicz, M.D., and J. Dolovich, M.D., S. Evans, B.A., Toronto, Ont. We report 7 cases of pentothal anaphylaxis over a 5 year period. 6/7 were female. Average age was 33(range 22-48 years). One patient was atopic. Within minutes of exposure to pentothal patients developed the following symptoms: Flush- ing/tachycardia(6/7), hypotension(5/7), diffi- culty with ventilation(4/7), urticaria(5/7), cu- taneous angioedema(3/71, laryngeal edema(2/7). Patients were skin tested at least 4 weeks post anaphylaxis. All demonstrated > 5mm wheal and flare to pentothal from 1:lOOO to 1:lO dilu- tion by either prick or intradermal skin tests. Passive transfer was positive in 1 patient. 6 controls were skin test negative. In the RAST method pentothal was covalently bound to epoxyactivated sepharose beads. Unbound sites on the beads were occupied by the addition of ethanolamine. Beads were incubated with serum and following washing 1251-labelled anti-IgE was added. Results were expressed as the ratio of IgE bound to beads treated with pentothal and ethanolamine over beads treated with ethanola- mine alone. 4/5 patients with pentothal ana- phylaxis were definitely positive when compared with normal IgE and ragweed allergic high IgE controls, We conclude: ljpentothal anaphylaxis is not uncommon; 2)specific skin tests and RAST testing support this as IgE mediated and 3)such testing should be done in all general anaesthetic ana- phylactic or anaphylactoid reactions. 209 METABISULFITE (MB.91 SKIN TESTING IN 2000 ALLERGY CtiINIG PATIENTS. James Ii. Wells, M.D.L Oklahoma City, ---- Uklnnamn -----i‘- . Posrtive with MBS have pre! reported in some 1 histories sitivity. In sug ;;,' e ;:i results of MBS skin 1 adult allersv clinic reDorted. -- PQPul ation are inic were a O!5? tients h,pne Positive and one equivocal bad positive intra- If 'd. 220
Transcript of 208 Pentothal anaphylaxis
PROT‘AMINE INDUCED SHOCK:EVIDENCE OF MAST CELL INVOLVEMENT JA Esplin,GL Sussman,IB Schwartz, Toronto,Ontario A 75 year old male underwent elective abdominal aortic aneurysm repair.Protamine sulfate 25m9/IV was given to reverse heparinisation.There was no prior history of exposure to Protamine. Within minutes he developed tachycardia(75S150 per minute),hypotension(l20/60~50 mm/Hg systolic) and non-cardiogenic pulmonary edema(PA wedge lOnung/Hg(nl 5-13mm/Hg),cardiac output 4.4 L/min, systolic vascular resistance 1264(nl 1130f178). There was progression of signs with evidence of severe hypoxia and shock lung(PAO2 SOmm/Hg on F102 1.00 and PEEP 12.5cm/H20)and lactic acid- osis(7.2annol/L(nl 3mmol/L).Massive capillary leakage was documented with a decrease of albumin to ll(n1 35-50).Urticaria also occurred. Workup excluded other causes(negative for D.I.C., sepsis,transfusion reaction,cardiogenic sources, and hypovolemia).There was no evidence of comp- lement activation.Complete reversal of all signs and symptoms occurred within 14 hr.Subs.equent workup with Protamine prick and intradermal skin tests were negative.Prick skin tests with fish and salmon were also negative-serial tryp- tase activity was taken at the time and detected mild but noteworthy elevation(from 2.535.0 rig/ml at 5 hr.with a return to baseline at 9 hr).The peak level could have been missed,with the first post shock specimen drawn at 5 hr;at least after one complete half-life of decline.We conclude: 1)Protamine can produce non-cardiogenic pulmon- ary edema.2)Elevated tryptase with serial spec- imens suggest mast cell participation in this reaction.3)There is no evidence that this is IgE me_dia~ed,or..crass~reac~.s..~ftb fish or salmon.
enrerE, Malaga, Spain, True allergic reactions to lucal anesthetics can be under 1% of tutal adverse effects,They have chenical struc- tures in cummun and others different, Based un patch test results it seems that there is nut crussreactlvity arnung both groups, We present a 70 y,o, patient whu experienced five episudes of hyputensiun after using tetracain fur uretral dilatations, R controlled observation uf the patient introducing a catheter in the uretra with tetracain produced a severe hyputhensiun with generalised erythema and pruritus, Tutal IgE was 900 IU ml and a MST was develupped coupling nuvocaine tu HSA. The need of use uf local anesthetics justified the trial uf a compound of the amido group, Skin tests with incremental cuncentrations of lidocaine frun 0,2 till 20 mgr ml were negative, After injecting subcutaneously lml (50 mgrl a generalised erythena with pruritus appeared that was cuntrulled with antihistamines and adrenaline, After une year the patient was challenged again with lidocalne. Skintest with lidutaine were negative and an injectiun of 50 mgr in the forearm produced local erythema and pruritus in all the region, The procedure was repeated after 15 days giving the same reaction, The same amount was tested in five negative contruls wwith good tolerance. This case can be considered as having sensitivty tu both esther and amidu local anesthetics, The IgE to a RAST of nuvucaine-HSA was negative , Plthuugh the antigenic determinants and the inmunological mechanisms are not well known, in this case a common inmunolugical pathugenesis can produce sensitivty to both groups of anesthetics,
PENTOTHAL ANAPHYLAXIS. A, Cheema, M.D., G. L. Sussman, M.D., 2. Janoelewicz, M.D., and J. Dolovich, M.D., S. Evans, B.A., Toronto, Ont.
We report 7 cases of pentothal anaphylaxis over a 5 year period. 6/7 were female. Average age was 33(range 22-48 years). One patient was atopic. Within minutes of exposure to pentothal patients developed the following symptoms: Flush- ing/tachycardia(6/7), hypotension(5/7), diffi- culty with ventilation(4/7), urticaria(5/7), cu- taneous angioedema(3/71, laryngeal edema(2/7).
Patients were skin tested at least 4 weeks post anaphylaxis. All demonstrated > 5mm wheal and flare to pentothal from 1:lOOO to 1:lO dilu- tion by either prick or intradermal skin tests. Passive transfer was positive in 1 patient. 6 controls were skin test negative.
In the RAST method pentothal was covalently bound to epoxyactivated sepharose beads. Unbound sites on the beads were occupied by the addition of ethanolamine. Beads were incubated with serum and following washing 1251-labelled anti-IgE was added. Results were expressed as the ratio of IgE bound to beads treated with pentothal and ethanolamine over beads treated with ethanola- mine alone. 4/5 patients with pentothal ana- phylaxis were definitely positive when compared with normal IgE and ragweed allergic high IgE controls,
We conclude: ljpentothal anaphylaxis is not uncommon; 2)specific skin tests and RAST testing support this as IgE mediated and 3)such testing should be done in all general anaesthetic ana- phylactic or anaphylactoid reactions.
209 METABISULFITE (MB.91 SKIN TESTING IN 2000 ALLERGY CtiINIG PATIENTS. James Ii. Wells, M.D.L Oklahoma City, ---- Uklnnamn -----i‘- . Posrtive with MBS have pre! reported in some 1 histories sitivity. In
sug ;;,' e
;:i results of MBS skin 1 adult allersv clinic reDorted. -- PQPul ation are
inic were a O!5? tients
h,pne Positive and one equivocal bad positive intra-
If 'd.
220
