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Role of Rescue Transesophageal Echocardiography During Intraoperative Anaphylaxis Complicated by Dynamic Left Ventricular Outflow Tract Obstruction

Published:December 23, 2022DOI:https://doi.org/10.1053/j.jvca.2022.12.014
      ANAPHYLAXIS IS SUSPECTED when there is dysfunction in ≥2 organ systems after exposure to a suspected antigen.
      • Sampson HA
      • Munoz-Furlong A
      • Campbell RL
      • et al.
      Second symposium on the definition and management of anaphylaxis: Summary report–Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium.
      Findings may include urticaria, mucosal edema, gastrointestinal distress, bronchospasm, or hypotension. It also can be diagnosed in adults who have a sudden decrease in systolic blood pressure to <90 mmHg or a ≥30% decrease from baseline blood pressure after exposure to a known allergen. An elevated serum tryptase concentration helps to confirm the diagnosis, as it is a marker for mast cell degranulation.
      • Sampson HA
      • Munoz-Furlong A
      • Bock SA
      • et al.
      Symposium on the definition and management of anaphylaxis: Summary report.
      However, in patients with end-stage renal disease (ESRD), tryptase has been shown to be elevated at baseline, which confounds the diagnosis of anaphylaxis.
      • Sirvent AE
      • Gonzalez C
      • Enriquez R
      • et al.
      Serum tryptase levels and markers of renal dysfunction in a population with chronic kidney disease.
      In the perioperative setting, there are numerous possible triggers for allergic reactions and anaphylaxis, including neuromuscular blocking agents, antibiotics, blood products, chlorhexidine, and latex.
      • Garvey LH
      • Dewachter P
      • Hepner DL
      • et al.
      Management of suspected immediate perioperative allergic reactions: An international overview and consensus recommendations.
      The first-line treatment for anaphylaxis is epinephrine, a proven life-saving intervention.
      • Brown JC
      • Simons E
      • Rudders SA.
      Epinephrine in the management of anaphylaxis.
      Herein, the authors describe the usefulness and importance of 2-dimensional echocardiography in altering the management of an adult patient undergoing renal transplant surgery experiencing anaphylaxis resulting from antibiotic administration. Echocardiography revealed significant left ventricular outflow tract (LVOT) obstruction as the etiology of worsening hemodynamic collapse refractory to epinephrine administration. This finding prompted the institution of appropriate measures to treat concomitant anaphylaxis and dynamic LVOT obstruction, resulting in full patient recovery.

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