P048: PERIOPERATIVE ANAPHYLAXIS RESISTANT TO EPINEPHRINE: IMPACT OF BETA-BLOCKER THERAPY
Jacob D King, DO1; Christian Guier, BS2; Philip Lowman1; Ryan Chadha, MD1; Michael Smith, MD1
1Mayo Clinic Florida; 2Philadelphia College of Osteopathic Medicine
Perioperative anaphylaxis is a rare but serious complication of general anesthesia, most commonly triggered by neuromuscular blocking agents (69%), followed by natural rubber latex (12%), antibiotics (8%), hypnotics (3.7%), colloids (2.7%), opioids (1.4%), other (3%). Rapid diagnosis and intervention are essential to prevent severe outcomes, including death. Management can be further complicated by concurrent medications like beta-blockers, which can blunt the effects of epinephrine by competitively inhibiting catecholamine activation of beta receptors. In anaphylaxis, where epinephrine is crucial for stimulating the sympathetic response, beta-blockers may reduce its effectiveness, necessitating alternative treatments such as glucagon to reverse beta blockade and restore hemodynamic stability.
A 72-year-old male with a history of atrial fibrillation (on Pradaxa and sotalol), tobacco use disorder with baseline wheezing presented for scheduled laryngoscopy with TruBlue laser excision. Following induction with fentanyl, lidocaine, rocuronium, and propofol, the patient was impossible to mask ventilation followed by an easy intubation with video laryngoscopy. minimal to no etco2 was captured, it was determined the patient developed a severe bronchospasm and was also hypotensive with an erythematous rash. Anaphylaxis was high on the differential.
Treatment was initiated with boluses of epinephrine, calcium, and vasopressin. Followed by methylprednisolone, diphenhydramine, albuterol, and famotidine. There was limited improvement, the case was terminated and the patient was transferred to the ICU on an epinephrine infusion. A glucagon bolus was administered, resulting in moderate improvement, followed by a continuous infusion due to concerns that sotalol, a nonselective beta-blocker, could competitively inhibit Beta-2 receptors, limiting epinephrine's ability to relieve bronchospasm.
In the ICU, the patient's ETT was exchanged for a larger size (8.0). He remained hypotensive and bradycardic, requiring ongoing epinephrine infusion. Intermittent hypoxia required 100% FiO2 and high-dose albuterol. The glucagon infusion was continued overnight. The next morning, the patient was weaned off of infusions and was able to be extubated.
Elevated tryptase levels confirmed anaphylaxis. Skin allergy testing showed sensitivity to rocuronium and atracurium, with negative results for succinylcholine and vecuronium. The case was rescheduled in which he received vecuronium with no complications.
This case highlights the critical need for rapid recognition and management of perioperative anaphylaxis, especially in patients on beta-blockers. When epinephrine alone is inadequate, alternative rescue strategies such as glucagon should be considered early. Additionally, thorough perioperative allergy evaluation is essential for guiding future anesthetic planning and minimizing risk.