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2023

ANUÁRIO DO HOSPITAL
DONA ESTEFÂNIA

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A CASE OF CARDIAC ARREST DURING ANESTHESIA

Pedro Simão Coelho1, Sónia Rosa1, Paula Leiria Pinto1

1 - Serviço de Imunoalergologia, Centro Hospitalar Universitário de Lisboa Central, Lisboa

- EAACI Congress 2021, reunião internacional, apresentação sob a forma de E-poster

Introduction: Cardiac arrest (CA) during the perioperative period (POP) is a rare event associated with high mortality. CA’s etiology during spinal anesthesia is controversial. Its major causes can be a drug overdose, systemic drug toxicity, neuraxial block with sympathicolysis, abrupt positional changes, and hypovolemia. Anaphylaxis, however, is not generally considered. 
Case Report: We present the case of a 62-year-old woman referred to our department after an episode of CA and another of severe hemodynamic instability that happened during two different POP. The patient needed patellar fracture repair, personal history was irrelevant, and there were no known allergies. The first anesthetic induction was performed by subarachnoid block with bupivacaine in addition to sulfentanyl, droperidol, midazolam, and cefazolin. After 10 minutes, she presented with impaired mental state, bradycardia and evolved to CA. Advanced life support was started, and adrenaline and atropine were administered, with full recovery after 12 minutes. On the second episode, she was submitted to general anesthesia using during induction, midazolam, fentanyl, propofol, rocuronium, dexamethasone, and cefazolin. Eighteen minutes after, she developed hemodynamic instability and hypoxemia with total recovery after adrenaline administration. Skin, respiratory or gastrointestinal complaints were not observed, and the fracture was not repaired. Skin tests were performed with latex and all drugs used during both procedures according to the anesthetic report. All were negative except for cefazolin, with positive results in the immediate reading. The patient was posteriorly skin tested to other beta-lactams and submitted to oral provocation tests with amoxicillin and cefuroxime that were both negatives. Finally, she was successfully submitted to surgery with vancomycin as prophylaxis.
Conclusion: In this case, anaphylaxis was the cause of CA, and cefazolin the culprit. It emphasizes that despite atypical manifestations as bradycardia and absence of skin and respiratory symptoms, anaphylaxis should not be discarded. An investigation based on the anesthetic report was crucial to find the drug responsible, to prevent future episodes and find safe alternatives. 

Palavras Chave: Drug allergy; perioperative anaphylaxis