We report a case of severe anaphylactic shock in a 5-month-old infant who was scheduled to undergo an external inguinal hernia repair under general anesthesia. Rocuronium used for anesthesia induction was the most likely cause of anaphylaxis. High levels of serum tryptase and histamine detected in the blood sample collected during the anaphylactic reaction confirmed the diagnosis of anaphylactic shock. The patient’s clinical status improved within 90 min of intervention by the intravenous injection of vasopressors and a steroid. Surgery was canceled, and the patient stayed in the pediatric intensive care unit (PICU) under artificial ventilation for 5 h before safe extubation. The patient achieved full recovery the next day, without any sequelae. The rescheduled surgery was successfully completed 5 months later under general anesthesia without the use of neuromuscular blocking agents.
The reported incidence of perioperative anaphylaxis ranges between 1:3500 and 1:20,000, with a mortality rate of 3.4% [
A 5-month-old, 7.1 kg male infant was scheduled for an external inguinal hernia repair under general anesthesia. Anesthesia was induced using the slow induction method, with the inhalation of a mixture of oxygen, nitrous oxide, and 2.5% sevoflurane, as well as subsequent intravenous injections of atropine sulfate (0.1 mg) and rocuronium (7.5 mg). Anesthesia was maintained under controlled ventilation using a mixture of air, oxygen, and 2% sevoflurane, with a small dose of intravenous fentanyl (5 µg). Approximately 3 min after tracheal intubation, erythema, facial edema, tachycardia, and hypotension were observed, and manual ventilation suddenly became very difficult. The patient’s transdermal systolic blood pressure decreased to 40 mmHg (
The treatment for anaphylactic shock was immediately initiated with intravenous bolus injections of phenylephrine (0.01 mg) given six times, followed by ephedrine (0.4 mg) bolus injections given three times. His blood pressure gradually increased to 100/50 mmHg. Emergency invasive blood pressure measurement from the radial artery was established, and the scheduled surgery was cancelled. Methylprednisolone (50 mg) was also administered. After approximately1 h of observation in the operating room, the patient was transferred to the pediatric intensive care unit (PICU) under artificial ventilation, with intravenous midazolam for sedation. The patient was administered antihistaminic drugs and sedated with a continuous intravenous infusion of midazolam and dexmedetomidine in the PICU. His vitals became stable during the next 5 h, and he was safely extubated after no evidence of laryngeal edema was found by laryngoscopy. The next morning, he was transferred to the general pediatric ward and was discharged on the fifth day after the anaphylactic shock.
Subsequently, serum tryptase, histamine, and non-specific immunoglobulin (Ig)E levels in the blood sample collected 1 h after the shock were measured. Serum tryptase and histamine levels were high at 15.8 μg/L (normal, <8 μg/L) and 1.95 ng/ml (0.15 - 1.23 ng/mL), respectively; however, the non-specific IgE level was within normal limits at 102 IU/mL. Two months after discharge, allergen tests performed by the pediatric department
detected many food sources, including milk, wheat, rice, egg yolk, egg white, and ovomucoid, as allergens in this patient.
Five months after the anaphylactic shock, the external inguinal hernia repair was performed. Before anesthesia, a route for intravenous injections was established at the pediatric ward while the patient was awake. In the operating room, after the intravenous injection of atropine sulfate, general anesthesia was induced with the inhalation of a mixture of nitrous oxide, oxygen, and 5% sevoflurane, and suxamethonium chloride for laryngospasm was prepared for emergency use. After sufficient anesthesia was achieved with inhalation by mask ventilation, a supraglottic airway device (Laryngeal Mask ProsealTM; size, 1.5) was inserted through the oral cavity with no use of muscle relaxants or narcotics. Anesthesia with spontaneous respiration was maintained under the continuous inhalation of a mixture of nitrous oxide, oxygen, and 2.5% - 3.0% sevoflurane. Surgery was completed without complications. The patient was extubated in the operating room after recovery from anesthesia with no problems and was discharged the next day.
Several epidemiological studies and case reports about rocuronium and anaphylaxis have been reported up until today [
In summary, we report a case of severe anaphylactic shock in a 5-month-old infant who was scheduled to undergo external inguinal hernia repair under general anesthesia. Rocuronium used during anesthesia induction was the most likely causative agent. High levels of serum tryptase and histamine supported the diagnosis of anaphylactic shock. The planned surgery was canceled, and the rescheduled surgery was successfully completed 5 months later under general anesthesia with a supraglottic airway device and in the absence of any NMBAs. This case gives us a caution that rocuronium can be a causative of severe anaphylactic shock even in infants.
Authors thank the patient’s parent for their written permission to publish the case.
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Hideya Katoh,Yoshifumi Naito,Chihiro Aoki,Mao Kinoshita,Yoshinobu Nakayama,Teiji Sawa, (2016) Suspected Anaphylactic Shock Associated with Rocuronium in an Infant: A Case Report. Open Journal of Anesthesiology,06,51-54. doi: 10.4236/ojanes.2016.64008