Management of a Parturient with Mast Cell Activation Syndrome: An Anesthesiologist’s Experience

Table 5

Perioperative drugs and mast cell disease.

Class	Drug	Usage in mast cell disorders
Hypnotic/sedative agents	Propofol, dexmedetomidine, etomidate, ketamine	Acceptable
	Methohexital, thiopental	Thiopental causes histamine release
Inhalational anesthetics	Halogenated (isoflurane, sevoflurane, desflurane), nitrous oxide	Acceptable
Benzodiazepines	Midazolam, diazepam	Acceptable
Opioids	Morphine, meperidine, codeine	Causes histamine release
	Hydromorphone, fentanyl, sufentanil, alfentanil, remifentanil, buprenorphine	Acceptable
Nonopioid analgesics	Acetaminophen	Acceptable
	NSAIDs (ketorolac, nefopam)	Causes overproduction of leukotrienes (a mast cell mediator)
Neuromuscular blocking agents	Depolarizing NMBA (succinylcholine)	Acceptable
	Nondepolarizing aminosteroids (rocuronium, vecuronium pancuronium)	Acceptable
	Nondepolarizing benzylisoquinolines (atracurium, mivacurium, cisatracurium)	Atracurium and mivacurium cause histamine release
Reversal of neuromuscular blockade	Neostigmine, sugammadex	Acceptable
Local anesthetics	Amides and esters	Acceptable
Antiseptics	Alcohol, chlorhexidine, povidone-iodine	Acceptable
Intravenous fluids	Crystalloids, colloids, albumin, gelatin, hydroxyethyl starch	Acceptable
Common labor and delivery drugs	Oxytocin, prostaglandins, methylergonovine, tocolytic agent (terbutaline)	Acceptable, though role of prostaglandins in causing or worsening reactions is unclear
Antibiotics	Penicillins, cephalosporins, sulfonamides, vancomycin, polymyxin B, clindamycin, fluoroquinolones	Vancomycin and polymyxin B can cause histamine release
Miscellaneous	Adenosine, atropine, glycopyrrolate, ondansetron, beta-blockers, ACEI, protamine, aprotinin (fibrin glue), blood transfusion, dyes, contrast media, and latex	Acceptable; adenosine and protamine can cause histamine release; beta-blockers can attenuate the effect of epinephrine in anaphylaxis; ACEI can augment an anaphylactic reaction

NSAIDs: nonsteroidal anti-inflammatory drugs; NMBA: neuromuscular blocking agents; ACEI: angiotensin converting enzyme inhibitors. associated with histamine release should be avoided if another equally effective drug can be used; alternatively, they must be administered slowly. reported to cause in vitro histamine release from human mast cells. and products associated with high incidence of hypersensitivity reactions in the general population do not need to be avoided unless a previously documented sensitivity exists.