000098 - A peri-Anesthetic Reaction in a Pediatric Patient with Anaplastic Astrocytoma of the Body's Corpus Callosum

The incidence of peri-anesthetic reactions in the general population is estimated to be in the range of 1:353-1:18.600 procedures. In pediatrics, it is estimated that the incidence is lower than in adults, likely due to reduced latex use in operating rooms, lower prior medication/anesthetics sensitization, and less frequent prophylactic antibiotic use in children.

Symptoms in these reactions develop rapidly and can compromise the patient's life.Identifying the triggering drug is a challenge for the allergist since these patients often receive multiple medications during the perianesthetic period.

A 3-year-old male patient diagnosed with grade III anaplastic astrocytoma of the corpus callosum presented during his second surgical resection an immediate anaphylactic reaction following the iv administration of propofol, fentanyl, rocuronium, remifentanil, tranexamic acid, ceftriaxone, vancomycin, levetiracetam (concomitant medication, regularly administered orally), and cisatracurium: hypotension (80/20 mmHg), tachycardia (110 bpm), eyelid edema, and generalized urticaria. The patient required the administration of 2 doses of 0.1mg epinephrine i.m. fluid therapy dexamethasone i.v. and  with total recovery, allowing the surgery to be completed

Tryptase Levels: baseline: 3µg/L; 1 hour after onset of symptoms: 6µg/L; 17 hours after: 8µg/L (exceeding 1.2baseline+2 threshold as to be considered significant rise).

Skin-tests (prick/intradermal): Negative for propofol, fentanyl, remifentanil, tranexamic acid, ceftriaxone, vancomycin, and rocuronium. Mildly positive for cisatracurium in the intradermal test at 0.02mg/ml (possibly nonspecific histamine release, also positive in the control).

Basophil-Activation Test: Positive for propofol at 100g/ml. Near the positivity threshold for rocuronium and vancomycin. Negative for cisatracurium and fentanyl.

Challenge tests:

-Post-Anesthesia Care Unit: fentanyl (1mcg/kg) i.v., propofol (3mg/kg) i.v., and chlorhexidine: negatives.

-Allergy Day Hospital: vancomycin (400mg) i.v. and ceftriaxone (1.200mg) i.v.: negatives.

-Not performed with neuromuscular blocking agents due to high rish.

The patient continued to receive and tolerate levetiracetam after surgery.

We present a case of perioperative anaphylactic shock likely related to neuromuscular blocking agents, without demonstrating an immunological mechanism.

Anaphylactic shock may have been caused by cisatracurium through nonspecific mast cell activation with a possible role of levetiracetam.

It is recommended to have joint action protocols with Anesthesiology for the documentation, management of these reactions and scheduling of challenge tests requiring a post-anesthesia care unit.