Refractory Unforeseen Anaphylaxis Case in a Rural OR Unit
Table 1
Timeline of events relevant to patient’s admittance to day surgery and anaphylactic reaction.
Timeline of events
12:15
Patient preop vitals BP 111/94 mmHg, HR 54 bpm, and O2Sat 97%. Patient was brought into the operating theatre, feeling well. Monitors applied to patient, “time-out” done. Cefazolin 2 g IV infused, followed by midazolam 2 mg IV.
12:17
A few seconds after midazolam was initiated, she reported a feeling of “doom,” itching in the face and chest, followed by difficulty in breathing and loss of consciousness. Prominent flushing was noted over face and chest. Profound hypotension (BP of 70/45 mmHg) despite a first dose of epinephrine 0.4 mg IM within one minute of symptoms. Patient heart rate was 115 bpm and O2Sat was 80%.
12:18
Diphenhydramine 50 mg IV, ranitidine 50 mg IV, and dexamethasone 8 mg IV were given. 2 L fluid bolus was started under pressure. Pulse was nonpalpable for less than 10 seconds, code blue called with rapid response from OR team. The airway remained patent and pulse returned spontaneously before compressions were initiated.
12:21
Salbutamol was administered, second dose of epinephrine 0.4 mg IM given, along with two boluses of 5 mcg IV epinephrine followed by a continuous infusion. Patient regained consciousness, after approximately 3-4 minutes of absence. She continued to feel weak and reported that her face was swollen.
12:30
Received odansetron IV for nausea. The airway was continuously monitored out of concern for a need to intubate; however, it remained patent and oxygen was supplemented via nasal prongs. On auscultation, there was no significant wheezing. She improved clinically with the epinephrine infusion.
