Abstract
Purpose
To report a first case of probable anaphylactoid reaction to 6% hydroxyethyl starch reconstituted in balanced electrolyte and glucose solution (Hextend®).
Clinical features
A 22-yr-old man was admitted for a partial nephrectomy. Near the end of the four-hour operation, an infusion of Hextend® was initiated. Shortly thereafter, mechanical ventilation became difficult, peak inspiratory pressure increased to 55 cm H2O with audible wheezing over the patient’s lungs. Blood pressure suddenly decreased to 68/46 mmHg. Multiple doses of phenylephrine, ephedrine and epinephrine were required to restore the patient’s blood pressure. Postoperatively, a diffuse urticarial rash was apparent on his upper torso. The patient recovered uneventfully. His postoperative serum tryptase was 26.3 ng·mL-1 (reference range, < 11.5 ng·mL-1) and the urine N-methyl-histamine was 2448 μg·g-1 creatinine (reference range, 30–200 μg·g-1 creatinine). Two months after the event, skin testing was conducted to test for possible allergy to latex, lidocaine, propofol, cisatracurium, succinylcholine, vecuronium, midazolam, fentanyl, ondansetron, neostigmine, and cephazolin, and all were negative. Hextend® was also tested, starting with a 1:100,000 dilution and the results were negative.
Conclusions
The temporal relationship of severe hypotension, bronchospasm and skin rash within ten minutes from administration of Hextend® in this patient suggests an immediate hypersensitivity reaction to hetastarch. The elevated levels of serum tryptase and urinary N-methyl-histamine suggest that this hypersensitivity was mediated from mast cell degranulation. Negative skin testing suggests that the reaction was anaphylactoid.
Résumé
Objectif
Présenter un premier cas de réaction anaphylactoïde probable à de l’amidon hydroxyéthylé reconstitué à 6% dans une solution de glucose et d’électrolyte balancée (Hextend®).
Éléments cliniques
Un homme de 22 ans a été admis pour une néphrectomie partielle. Vers la fin de l’opération de quatre heures, une perfusion d’Hextend® a été amorcée. Peu après, la ventilation mécanique est devenue difficile, la pression inspiratoire maximale est montée à 55 cm H2O et s’accompagnait de sifflement perceptible à l’auscultation des poumons. La tension artérielle a soudainement chuté à 68/46 mmHg. De multiples doses de phényléphrine, d’éphédrine et d’épinéphrine ont été nécessaires pour restaurer la tension artérielle du patient. Après l’opération, une éruption urticarienne était apparente à la partie supérieure du torse. Une récupération sans incident a suivi. La tryptase sérique postopératoire a été de 26,3 ng·mL-1 (étendue de référence, < 11.5 ng·mL-1) et la N-méthyl-histamine urinaire a été de 2448 μg·g-1 de créatinine (étendue de référence, 30–200 μg·g-1 de créatinine). Deux mois après l’événement, des tests d’allergie cutanée au latex, à la lidocaïne, au propofol, au cisatracurium, à la succinylcholine, au vécuronium, au midazolam, au fentanyl, à l’ondansétron, à la néostigmine et à la céphazoline ont été menés et se sont tous révélés négatifs. Le Hextend® a été aussi testé, en commençant avec une dilution à 1:100 000 et les résultats ont été négatifs.
Conclusion
La relation temporelle entre l’hypotension sévère, le bronchospasme et l’éruption cutanée en moins de dix minutes après l’administration du Hextend® laisse croire à une réaction d’hypersensibilité immédiate à l’hétamidon. Les niveaux élevés de tryptase sérique et de N-méthyl-histamine urinaire indiquent que cette hypersensibilité origine d’une dégranulation des basophiles. Les tests cutanés négatifs montrent que la réaction était anaphylactoïde.
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Support for this study is provided from the Department of Anesthesiology and Division of allergic Diseases and Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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Hall, B.A., Frigas, E., Matesic, D. et al. Case report: Intraoperative anaphylactoid reaction and hydroxyethyl starch in balanced electrolyte solution (Hextend®). Can J Anesth 53, 989–993 (2006). https://doi.org/10.1007/BF03022527
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DOI: https://doi.org/10.1007/BF03022527