Peter Sherren

NOT EVERY SWOLLEN FACE IS ANAPHYLAXIS

In 1990, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) published its first report on suspected anaphylactic reactions associated with anaesthesia.

The reported suspected that, between 1995-2001, anaphylactic reactions related to anaesthesia in the UK averaged 55 per year, compared with 319 for all drugs1.

10% of anaesthetic reports were of fatalities compared with 3.7% for all drugs reported1.

The understandable concentration on anaphylaxis within anaesthesia means that the knowledge of differential diagnoses and therapeutic options may be limited.

66 yr-old Afro-Caribbean lady

Htn, DM, IHD and PPM 05.00 Sudden onset tongue

swelling and DIB Called to DGH ED 06.15 Dramatic angioedema+,

drooling++, stridor, poor vocalisation, agitated, SpO2

~92% FiO2 0.85 FM. CVS stable

MP V?

Unexpected complication of treatment. Unresponsive to steroids/anti-histamines/adrenaline. ODP transported difficult airway trolley to resus. Surgical Spr not happy/competent to perform emergency awake

trache. 18g cannula cricothyroidotomy performed pre-induction

uneventfully. RSI, Grade III/IV (oedematous, distorted anatomy) view with McCoy. GEB sited 3rd pass. Unable to pass 7.0 coett, 6.0 passed with difficulty, minimal leak

with no cuff deflated. No issues ventilating. Progression of angioedema post intubation. 10 day ICU admission, discharged to ward neurologically intact with

trache insitu.

Out of hours communication/mobilisation of staff and equipment outside of theatres.

Familiarity with, and applied use of equipment on a well-stocked (theatre) difficult airway trolley.

Flexible use of DAS algorithm.

Inadequate difficult airway trolley in ED.

Rail-roading size 6.0 coett over 15F bougie is fiddly. Any smaller would have required a CHANGE of bougie for a 10F.

Retrospectively, the needle cricothyroidotomy was unnecessary, exposing already difficult airway to potential trauma.

General surgical training inadequate?

Causes of angioneurotic oedema Idiopathic- large proportion. Mast cell related/anaphylaxis. Hereditory (HAE) I and II- C1 inhibitor deficiency or dysfunction. Acquired- immunosuppression and lymphoproliferative disorders. Drug related- Aspirin/NSAIDS, ACE, opiates, abx.

ACE inhibitors related angioneurotic oedema2,3: Now most common exogenous cause of angioedema seen. Can occur any time from initiation through to 10 years into treatment. 0.1-0.5% of those receiving the drug. Usually has no associated urticaria. Due to increased bradykinin levels because kinin degradation is

inhibited. Can cause dramatic swelling of tongue, pharynx, or larynx- Secure

airway early. Deaths related to AIRWAY, no reported deaths from primary CVS

collapse. Some response to Adrenaline and minimal to steroids and anti-

histamines.

In angioneurotic oedema (like burns):• Use of size 10F bougie• Use of uncut COETT • Range of sizes of COETT ready for use

Potential unique use of the Melker vs other large bore cricothyroidotomy kit

Improvement/standardisation of difficult airway trolley in ED

Choice of large bore cricothyroidotomy kit?• CUFFED seldinger vs PCK vs Quicktrach II

Place for selected pre-emptive cannula cricothyroidotomy and later use of Melker?

1. AAGBI Working party. SUSPECTED ANAPHYLACTIC REACTIONS ASSOCIATED WITH ANAESTHESIA. AAGBI Revised Edition 2003. www.aagbi.org

2. Adebayo PB, Alebiosu OC. ACE-I induced angioedema: a case report and review of literature. Cases J. 2009 Jul 27;2:7181.

3. Cupido C, Rayner B. Life-threatening angio-oedema and death associated with the ACE inhibitor enalapril. S Afr Med J. 2007 Apr;97(4):244-5