D3.306 - Veno-Venous ECMO For Aprotinin-Induced Perioperative Anaphylaxis

Veno-Venous ECMO for Aprotinin-Induced Perioperative Anaphylaxis

Background:Perioperative anaphylaxis is a rare but potentially fatal complication of anesthesia and surgery. Antifibrinolytic agents are uncommon triggers and may be overlooked during acute intraoperative reactions. Severe respiratory-dominant anaphylaxis requiring extracorporeal support has been rarely described.

Methods:We report a case of aprotinin-induced perioperative anaphylaxis occurring during elective cardiac surgery. Clinical course, biochemical confirmation, extracorporeal management, and post-event allergologic evaluation were reviewed.

Results:A 51-year-old man undergoing aortic valve replacement developed sudden severe bronchospasm and profound refractory hypoxemia approximately three hours after induction of anesthesia, during separation from cardiopulmonary bypass, shortly after intravenous aprotinin administration. Oxygen saturation rapidly declined to 70% despite maximal ventilatory support, bronchodilator therapy, and lung recruitment maneuvers, while hemodynamic stability was preserved. Cardiopulmonary bypass was urgently reinstituted, followed by initiation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) due to life-threatening respiratory failure. Oxygenation improved immediately after ECMO initiation. Serum mast cell tryptase measured one hour after the event was markedly elevated (106 µg/L; reference <11 µg/L), confirming mast cell activation. The patient was successfully decannulated from ECMO after 24 hours, extubated on postoperative day 1, and achieved complete respiratory recovery. Postoperative allergy evaluation performed according to EAACI/ENDA recommendations demonstrated a positive intradermal test to aprotinin, confirming it as the causative agent, while all other perioperative drugs tested negative.

Conclusion:Aprotinin can trigger fulminant perioperative anaphylaxis with predominant respiratory failure even in the absence of prior exposure. Early recognition, multidisciplinary management, timely use of VV-ECMO, and comprehensive post-event allergologic evaluation are essential to ensure patient survival and prevent re-exposure.