Reactions Weekly | 2021
Cisatracurium besilate
Abstract
Anaphylactoid reaction and bronchospasm: case report A 23-year-old woman developed anaphylactoid reaction and bronchospasm following administration of cisatracurium besilate as a neuromuscular blocker [time to reaction onsets not stated]. The woman was admitted for scheduled laparoscopic bariatric surgery on 07 November 2018. Her medical history was significant for appendectomy, caesarean section and penicillin allergy. She had a 7-year smoking history (7 cigarettes/day), and had stopped smoking for 4 days prior to the operation. On 12 November 2018, after providing a high-flow mask oxygen, she was administered IV cisatracurium besilate 40mg [cis-atracurium; supplied by Jiangsu Hengrui Pharmaceutical Co. Ltd.] along with penehyclidine, prednisolone, midazolam, propofol and sufentanil. Breathing sounds were not heard in both lungs following tracheal intubation, and her end tidal CO2 (ETCO2) was noted continuously in waveform. On repeat auscultation, weak breath sounds were heard from both lungs with a lot of dry and wet rales. Negative pressure was used to suck sputum with only a small amount of clear secretions. Her airway pressure (Paw) was 40cm H2O and tidal volume (Vt) was 350mL with a hand-controlled ventilation. Her PaO2 was 81mm Hg, PaCO2 was 50.6mm Hg, SpO2 was 95%, SaO2 was 95% and fraction inspired O2 (FiO2) was 90%. Based on all the findings, a serious bronchospasm was suspected. The woman was treated with methylprednisolone and aminophylline. Her arterial blood gas analysis results after 15 minutes of treatment were as follows: PaO2 80mm Hg, PaCO2 46.3mm Hg, SpO2 95%, FiO2 90% and SaO2 95%. There was no significant fluctuation in haemodynamics, and her respiratory compliance had improved. Following intubation, pressure controlled ventilation was used, and her Vt was 350mL, Paw was 38cm H2O, RR was 12 breath/min, positive end-expiratory pressure (PEEP) was 5cm H2O, and slope was 1.0 seconds. Anamnesis after referring her to the Department of respiratory medicine revealed that she was a smoker, and it was considered that the airway sensitivity was likely to have cause airway spasm following endotracheal intubation. Thereafter, her family gave consent to stop the operation. One hour later, she had Vt was 450mL, Paw 35cm H2O, RR 12 breath/min, PEEP 5cm H2O and slope 1.0 seconds with significantly improved respiratory compliance. She was shifted to the ICU under moderate sedation. Two hours later, her respiratory function recovered and the tracheal tube was removed. At the time, her PaO2 was 96mm Hg, PaCO2 was 40.1mm Hg, SpO2 was 96%, FiO2 was 40% and SaO2 was 98%. She reported tracheal burning sensation the following day, which was considered to have developed by the pressure injury of the airway. The operation was again performed on 21 November 2018. At this time, she received methylprednisolone, aminophylline and atropine for prevention of airway spasm. The woman was again administered IV cisatracurium besilate 40mg along with penehyclidine, prednisolone, midazolam, propofol and sufentanil. She was then maintained on a hand-controlled ventilation was till the time spontaneous breathing disappears. During ventilation, her skin of anterior chest and neck was flushed, and she had high airway resistance without significant haemodynamic fluctuation. The anaesthesia was maintained with sevoflurane following tracheal intubation. On auscultation, a large number of dry and wet rales were heard in both lungs, and the airway resistance had significantly increased. The skin flushing resolved gradually five minutes later. At the time, her PaO2 was 98mm Hg, PaCO2 was 41.6mm Hg, SPO2 was 98%, FiO2 was 90% and SaO2 was 98%. The pressure ventilation mode was given, and her Pplat was 28cm H2O, RR was 12 breath/min, PEEP was 7cm H2O, slope was 1.0 seconds and Vt was 522mL. The breath sound was clear and the rales gradually disappeared one hour later. A repeat arterial blood gas analysis showed improvement. Her breathing recovered slowly, and she was again administered cisatracurium besilate 5mg. Subsequently, her airway pressure increased, and the lungs again showed a large amount of dry rales on auscultation. Based on all the findings, anaphylactoid reaction secondary to cisatracurium besilate leading to serious bronchial spasm was diagnosed. After improvement in her symptoms, she was again administered cisatracurium besilate and she developed bronchospasm symptoms immediately. Thereafter, rocuronium bromide was tried on which bronchospasm did not occur. Drug provocation test confirmed that the bronchospasm was caused by cisatracurium besilate. Hence, she was administered rocuronium bromide during the surgery and no allergic reactions were noted. Four hours later, she had PaO2 was 138mm Hg, PaCO2 was 56.2mm Hg, FiO2 was 90%, SpO2 was 99% and SaO2 was 99%. She was given sufentanil and methylprednisolone again for transition of respiratory function recovery. She was shifted to the ICU after the operation and tube was removed after 2h. During her next visit, she had no obvious discomfort and the rales had completely disappeared. Seven days later, she was discharged and no abnormalities were noted 4 weeks later.