An anaphylactic reaction possibly associated with an intraoperative coronary artery spasm during general anesthesia

We report a case of anaphylactic reaction occurring during general anesthesia that may have been accompanied by a coronary artery spasm. The present case and a review of the medical literature suggest that coronary artery spasm is evoked by common vasoactive mediators with anaphylactic reactions. Coronary artery spasm should be counted as a symptom of the cardiovascular manifestation of anaphylaxis. Clinicians should be aware of this possible complication when treating an anaphylactic reaction, especially in patients at risk for atherosclerosis. Early recognition of ST segment elevation is essential for diagnosis and treatment of coronary artery spasm.     

A case of anaphylactic reaction caused by sugammadex

A 17-year-old man was scheduled for ventriculo-peritoneal shunt under general anesthesia. Anesthesia was induced by propofol, rocuronium and pentazocine, and maintained with sevoflurane and nitrous oxide. The operation was finished in 1 hour and 4 minutes without trouble. After the operation, sugammadex was administered. After about 2 minutes, the redness and the wheal appeared in the body trunk, and SpO2 dropped to The appearance of rapid symptom immediately after administration of sugammadex indicated that anaphylactic reaction had occurred. We administered adrenaline. After the administration of adrenaline several times, cutaneous findings became improved and SpO2 was stabilized. We started continuous infusion of adrenaline, and the patient was moved to the intensive care unit (ICU). Twelve hours after entering the ICU, the patient was extubated. He showed no troubles thereafter, and left hospital. After introduction of sugammadex to clinical use, 7 cases of anaphylactic reaction to sugammadex were reported. We must know that anaphylactic reaction can be induced by sugammadex.     

A case of anaphylactic shock in an elderly man following protamine sulfate administration during emergent off-pump coronary artery bypass grafting

An 80-year-old diabetic man undergoing emergent off-pump coronary artery bypass grafting for acute myocardial infarction developed anaphylactic shock immediately following administering a small dose of protamine sulfate. Preoperative examination revealed atrial fibrillation, severe three-vessel coronary artery disease and impaired left ventricular function with ejection fraction of 40% and severe septal as well as apical hypokinesis and akinesis. After successful completion of coronary bypass grafting, a total of 40 mg of protamine sulfate was given through the central venous line. Three minutes after protamine administration, profound hypotension occurred. Pulmonary artery pressure was low and the left ventricle was almost empty by transesophageal echocardiography. Hypotension was refractory to rapid administration of 2 l of crystalloid and albumin, and repeated administrations of phenylephrine. Blood pressure finally returned towards baseline after infusion of norepinephrine 0.2 microg x kg(-1) x min(-1) and epinephrine 0.1 microg x kg(-1) x min(-1). Hemoconcentration and impaired oxygenation were also noted. The situation suggested anaphylactic shock due to protamine. He had diabetes mellitus for 20 years and been treated by protamine containing insulin. Postoperative interview revealed that the patient had experienced urticaria over the abdominal area with neutral protamine hagedorn (NPH) insulin administration. This history suggested that the patient had been sensitized by protamine before surgery. Although it is rare to experience anaphylactic shock due to protamine, it is important to elicit the detailed allergic history to insulin in diabetic patients. Because anaphylactic shock still carries high mortality even in a patient without cardiac disease, we were lucky to save this elderly patient with acute myocardial infarction and compromised left ventricular function.     

Noncardiogenic pulmonary edema associated with protamine administration during coronary artery bypass graft surgery

Protamine sulfate is the only agent approved to reverse heparin-induced anticoagulation. As with any other drug, protamine has the potential to cause adverse effects that range from mild hypotension to potentially fatal events, such as noncardiogenic pulmonary edema (NCPE) and catastrophic pulmonary vasoconstriction. We report a case of NCPE after the administration of protamine to a patient undergoing coronary artery bypass graft surgery and discuss the diagnosis and management of this severe adverse event.     

Exercise-induced ST-segment elevation possibly caused by coronary artery spasm. A case presentation and review

A 36-year-old man with classic angina pectoris had marked ST-segment elevation (STE) in the inferior leads on stress-testing in the absence of chest pain. There was no evidence of previous myocardial infarction (MI). Selective coronary arteriography delineated severe obstructions in the right coronary artery (RCA) with additional left circumflex coronary artery (LCx) obstruction. Left ventricular cine-angiography established that there was normal contractility and confirmed the absence of past MI. Coronary artery bypass graft surgery to the RCA and LCx was unfortunately complicated by an acute transmural inferoposterolateral MI. Treadmill stress testing 6 weeks after surgery failed to demonstrate the preoperative ST-segment change. The patient may have developed exercise-induced coronary artery spasm superimposed on the severe proximal RCA stenosis; this in turn may have caused the inferior STE. Exercise-induced STE is reviewed.     

A case of coronary artery spasm caused by manipulation of the neck: heart rate variability analysis

A 66-year-old man with no history of ischemic heart disease underwent cervical lymph node dissection. General anesthesia was induced and maintained with remifentanil, along with propofol. With manipulation of the neck and a subcutaneous injection of lidocaine supplemented with adrenaline before the operation, a sudden decrease in blood pressure (BP) and elevation of the ST-T segment appeared on the monitoring electrocardiogram (ECG). Ephedrine, phenylephrine, adrenaline, and nitroglycerin were administered; however, the hypotension was sustained and the ECG abnormalities progressed, along with further elevation of the ST-T segment and a complete atrioventricular block. Following an injection of atropine, the changes in ECG and BP were attenuated. Heart rate variability (HRV) was analyzed using fully recorded monitor variables, and revealed an increase in the high-frequency domain at the time of the cervical manipulation, suggesting simultaneous vagal stimulation and coronary artery spasm. We concluded that the cervical manipulation had increased the vagal tone and we note that HRV analysis was useful to interpret this coronary event.     

A case of intraoperative repeated coronary artery spasm with ST-segment depression

A 68-year-old man with good left ventricular function underwent subtotal gastrectomy for gastric cancer under general anesthesia. Twenty minutes after the start of surgery, ST-segment depression was noted on the electrocardiogram monitor without change in the hemodynamic state. Intravenous isosorbide dinitrate relieved the electrocardiographic signs of ischemia. Short episodes of the ST-segment depression recurred 5 times despite intravenous isosorbide dinitrate and nicorandil. Echocardiography immediately after the surgery revealed hypokinesia of the anterior, septal and apical segments with an ejection fraction of 48%, suggesting acute myocardial infarction or the "Takotsubo"-shaped cardiomyopathy. However, a day after surgery, echocardiography showed improvement of regional wall motion with an ejection fraction of 57%. Coronary angiography showed normal coronary arteries on the 22nd day after the surgery. Patient manifested occlusive coronary artery spasm on ergonovine provocative test. We would like to stress that perioperative coronary artery spasm may demonstrate ST-segment depression and may result in severe consequences, regressive but relatively prolonged, in left ventricular function.     

Dramatic post-cardiotomy outcome, due to severe anaphylactic reaction to protamine.

Immunologic reactions to protamine sulfate during cardiac surgery are very rare. The frequency and outcome of such adverse reactions is unclear. We report a case of lethal anaphylactic reaction to protamine that occurred in a non-diabetic patient following the uneventful replacement of the ascending aorta. We also briefly review the mechanisms of this adverse reaction and emit some considerations on the management of this situation.     

Hemifacial spasm caused by a tortuous recurrent perforating artery: A case report

IntroductionWhen the culprit vessel in hemifacial spasm (HFS) is hard to determine, this is a challenge in microvascular decompression (MVD) surgery. In such a situation, small arteries such as perforators to the brainstem might be suspected. But small arteries are omnipresent near the facial nerve root exit/entry zone (fREZ). How to decide whether a given small artery is responsible for HFS is unclear.MethodWe report a case with a previously unreported form of neurovascular impingement, in which the culprit was found to be the recurrent perforating artery (RPA) from the anterior inferior cerebellar artery (AICA). An aberrant anatomic configuration of the RPA was found intraoperatively, which we thought was responsible for generating focal pressure on the facial nerve.Case reportA 62-year-old woman presented with a 1-year history of paroxysmal but increasingly frequent twitching in her right face. MRI showed tortuosity of the vertebral artery and apparently marked neurovascular impingement on the asymptomatic left side, while only the right AICA could be implicated as the possible culprit. Hemifacial spasm was diagnosed based on the typical clinical manifestation, and MVD was performed. The pre-meatal segment of the AICA was found not to be impinging the facial nerve at any susceptible portion near the fREZ: root exit point, attached segment, or root detachment point. The real culprit was in fact the RPA. This occult culprit vessel was tortuous, forming a coil-shaped twist which was interposed between the facial nerve and the intermediate nerve near the root detachment point. Focal pressure atrophy of the nerve was clearly observed at the compressing site. The patient achieved total spasm relief immediately after surgery, and remained spasm-free at 1-year follow-up, without any postoperative complications.ConclusionMVD is the only curative treatment for hemifacial spasm, but with a failure rate of around 10%. Mistaking the real culprit has been reported to be the most likely reason for surgical failure. Therefore, intraoperative identification of atypical occult forms of vascular compression is of importance to improve surgical outcome. In the present case, the RPA formed a coil-shaped twist, which inflicted focal vascular compression causing hemifacial spasm. We recommend careful inspection of the recurrent perforating artery during MVD for HFS, and decompressing any such neurovascular impingement.     

A case of intraoperative coronary artery spasm in a patient with vascular disease

A 66-year-old man with a history of longtime smoking, untreated hypertension, hyperlipidemia, and impaired glucose tolerance but no history of myocardial infarction or angina pectoris was scheduled for right aortofemoral bypass and thromboembolectomy for arteriosclerosis obliterans with right common iliac and right popliteal arterial thrombus. Epidural anesthesia and general anesthesia were administered without obvious ECG changes. Just after skin incision, ST elevation in leads II and V5 and a short run of ventricular tachycardia with frequent premature ventricular contractions (PVCs) were recorded on the ECG monitor, and the patient’s blood pressure suddenly decreased within a few seconds. On noticing these changes, we suspected coronary artery spasm (CAS) and rapidly administered vasodilators and vasopressors to stabilize hemodynamics and ECG changes. Transesophageal echocardiography (TEE) showed basal to mid- and anteroseptal to inferior wall motion hypokinesis that gradually returned to normal during observation. Even in patients without coronary disease but with systemic arteriosclerosis, it is important to consider the possibility of perioperative CAS and not to overlook ECG changes. Immediate diagnosis and treatment are essential.     

A case of cardiac arrest with coronary artery spasm during lumbar epidural anesthesia

A 61-year-old man underwent arthroscopic surgery for internal derangement of the knee joint under epidural anesthesia. Epidural catheterization was performed at the L 2-3 interspace. Operation was started with 10 ml of 1.5% lidocaine. Then 12 ml of 0.375% bupivacaine was added to epidural space. Twenty minutes thereafter, electrocardiogram demonstrated marked elevation of ST segment and atrio-ventricular dissociation, followed by cardiac arrest. Cardiopulmonary resuscitation was started immediately and after 25 minutes normal sinus rhythm was restored. The patient recovered with no neurological sequelae. Coronary angiogram examination was performed but no significant stenosis of coronary artery was observed. Coronary artery spasm caused by lumbar epidural anesthesia was suspected.     

A case of coronary artery spasm during epidural anesthesia with continuous infusion of propofol

A 50-year-old male patient was scheduled for left partial pulmonary resection and biopsy. The patient had neither complication nor history of ischemic heart disease. After arriving in the operation room, an epidural catheter was inserted into the epidural space at the T 4-5 intervertebral space. Anesthesia was induced with intravenous propofol 100 mg, fentanyl 100 microgram and vecuronium 6 mg and then a double lumen endotracheal tube was inserted. Anesthesia was maintained with O2 and air (FIO2 0.3-1.0), continuous infusion of propofol, intermittent intravenous administration of fentanyl and epidural injection of 1% lidocaine. Forty-five minutes after the start of operation, ECG showed an elevation of ST segment and soon it passed into ventricular tachycardia and ventricular fibrillation. The patient was treated with cardiopulmonary resuscitation. Fifteen minutes later, ECG returned to sinus rhythm but the elevation of ST segment remained. We considered that these cardiac events were due to coronary spasm, and started continuous infusion of nitroglycerin and nicorandil. One hour later, ST segment returned to normal. The possible inducing factors in this case were altered balance between sympathetic and parasympathetic nervous activity caused by infusion of propofol and epidural block, and alpha-stimulation caused by ephedrine.     

Hemodynamic changes after protamine administration: association with mortality after coronary artery bypass surgery

BACKGROUND: Protamine sulfate is standard therapy to reverse heparin anticoagulation. Hemodynamic responses to protamine are common, ranging from minor perturbations to cardiovascular collapse. Although severe fatal reactions occur, the relation of less extreme responses with postoperative mortality is unknown. Therefore, the authors tested the hypothesis that hemodynamic "protamine reactions" (systemic hypotension and pulmonary hypertension) are associated with mortality after cardiac surgery. METHODS: In a university hospital setting, the authors studied 6,921 coronary bypass patients using automated anesthesia record-keeping data and quality assurance databases. Degree/duration integrals of systemic hypotension (< 100 mmHg) and pulmonary hypertension (> 30 mmHg) for the 30-min after protamine administration were assessed for linear associations with mortality using multiple logistic regression models adjusting for risk factors. RESULTS: Overall mortality was 2%; greater hemodynamic responses were associated with increased mortality by odds ratios of 1.28 (systemic hypotension: 95% confidence interval, 1.14-1.43; P < 0.001) and 1.27 (pulmonary hypertension: 95% confidence interval, 1.06-1.48; P < 0.001) per 150-mmHg . min increment. Proximity of the response to protamine administration strengthened the relation, which persisted after exclusion of major hemodynamic disturbances. Tests for linearity confirmed an association even at the lowest range of values for both pressure effects. CONCLUSIONS: Hemodynamic perturbations after protamine administration are independently related to in-hospital mortality after primary coronary artery bypass surgery; the relation is present even in the lowest observed range of values for both systemic hypotension and pulmonary hypertension. Although randomized trials are necessary to address causality, this evidence suggests that strategies that avoid or attenuate these reactions may improve patient care.     

川崎病冠状动脉病变及搭桥手术

目的 探讨川崎病后严重冠状动脉病变及搭桥手术（ＣＡＢＧ）后的近期及远期效果。方法随访发现,６例川崎病后严重冠状动脉病变的病儿均有左冠状动脉前降支（ＬＡＤ）病变,右冠状动脉（ＲＣＡ）病变５例,左冠状动脉回旋支（ＬＣＸ）病变３例,左冠状动脉主干（ＬＭＴ）病变２例,心肌梗死３例。共行１５支ＣＡＢＧ;单支２例,３支３例,４支１例;左胸廓内动脉（ＬＩＴＡ）至ＬＡＤ６例;右胸廓内动脉（ＲＩＴＡ）至ＬＡＤ１例。     

A case of anaphylactic shock possibly caused by intravesical Hexvix

BACKGROUND: We report a case of a 69-year-old Caucasian male who experienced a severe drop in blood pressure and a skin rash after fluorescence cystoscopy and transurethral resection of the prostate. The diagnostic agent used for fluorescence cystoscopy and suspected of causing the anaphylaxis was hexaminolevulinate hydrochloride (Hexvix). INCIDENT: A profound fall in blood pressure associated with atrial fibrillation, the appearance of a rash, vomiting and transient loss of consciousness occurred immediately after surgery. The hypotension persisted for several hours despite intensive treatment. The reaction commenced approximately 5 h after exposure to Hexvix. There was an increase in serum tryptase (almost nine-fold) and a positive skin prick test to undiluted Hexvix. CONCLUSION: The mechanism of the anaphylaxis is uncertain, but is considered likely to be a non-immunoglobulin E-mediated allergic reaction possibly caused by Hexvix. This is the first reported case of a severe allergic reaction after intravesical instillation of Hexvix.     

A case of necrosis of a hepatocellular carcinoma, caused by spasm of the celiac artery

A 54-year-old man was admitted to our hospital complaining of back pain and right hypochondrial pain. Ultrasonography and celiac angiography revealed a large tumor sized 9.4 X 8.1 cm. The tumor appeared hypervascular on angiogram. During the second angiography, an attempt at superselective hepatic angiography for the purpose of infusing a combination of Adriamycin and Lipiodol, spasm of the celiac artery occurred. High fever continued for 11 days after the spasm and serum transaminase was elevated. At the third angiography, the nature of the tumor was seen to have changed remarkably to one of hypovascularity. Percutaneous transhepatic tumor biopsy was done. Pathological diagnosis was necrosis of hepatocellular carcinoma. Due to heart disorders, ligation of the right hepatic artery was performed instead of hepatic resection. Postoperatively, the size of the tumor decreased further. It is thought that this patient had a tendency to suffer from vasospasm and that the tumor had a relatively low resistance to ischemia.     

A case of quadricuspid aortic valve associated with coronary artery disease

A 65-year-old man with aortic regurgitation was found to have a quadricuspid aortic valve. Surgical correction consisted of aortic valve replacement with a 21 mm Hyper dynamic plus St. Jude Medical valve and coronary revascularization of LAD and the first diagonal branch. During the operation, a quadricuspid aortic valve with 1 smaller and 3 larger cusps and normal coronary orifice were noticed. Accurate information by the transesophageal echo proved to be quite valuable. Our case is one of 43 cases which have been reported in Japan.     

肾性抽搐致股骨颈骨折一例报告

患者女性,53岁,既往反复应用"龙胆泻肝丸"10余年,发现肾功能不全4年.此次因胸闷、憋气半个月入院,入院后血生化示尿素氮45.2 mmol/L,肌酐1112 μmol/L,血钙0.95mmol/L,血磷4.6 mmol/L.