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Sedation for an MRI for a Child with an Egg and Soy Allergy and a Recent Meal

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Sedation for an MRI for a Child with an Egg and Soy Allergy and a Recent Meal Sedation for an MRI for a Child with an Egg and Soy Allergy and a Recent Meal Pioneer in Pediatric Anesthesiology: Burton S. Epstein, M.D. Senior Faculty: Carolyn F. Bannister, M.D. Junior Faculty: Kenneth S. Stewart, D.O. OBJECTIVES After attending this session, the attendant should be able to: • Discuss options for sedation for an MRI. • Discuss anesthetic implications of Magnetic Resonance Imaging. • Cite ASA NPO guidelines including the updated ASA practice guidelines (3/11). • Discuss the anesthetic implications for multiple food allergies including egg allergy. • Create a plan for an offsite anesthetic emergency STEM CASE – KEY QUESTIONS A 4-year old male with a history of meningioma is coming for an MRI of the head. The tumor was resected 6 months ago and the patient has returned to his normal state of health. The MRI was ordered for surveillance and to check for postoperative changes. His last meal was toast, cheese, and apple juice 6 hours ago. The sedation service (non-anesthesia personnel) at your hospital does not feel comfortable with his NPO status and requests Anesthesiology’s help with this patient. He is an otherwise healthy boy with multiple food allergies including eggs and soy. 1. Is there anything else you would like to know prior to induction of anesthesia? 2. What monitors are appropriate for this case? 3. What do you think about his NPO status? What is your hospital’s policy in regards to NPO status? Are there any pharmacologic agents you would consider in regards to the patient’s NPO status (ex. ranitidine, etc.)? 4. How do you normally take care of patients for an MRI? Would you premedicate this patient? If yes, what would you use? Will you sedate or choose a GA? If sedation, what drugs will you use? 5. If GA, how would you induce anesthesia for this patient? What are your anesthetic concerns? You decide on a mask induction and will place an IV after the patient is asleep. The mask induction goes uneventfully. The vital signs at this time are HR=90s, Non-invasive BP=100/62, and O2 sat=100%. The anesthetist helping you places a tourniquet on the patient and proceeds in looking for an IV site. The anesthetist has difficulty finding and placing an IV. As she continues to look, it becomes harder to mask ventilate the patient. You are only able to move small tidal volumes and the patient is apneic. She finally places the IV and you decide to intubate. 6. What drugs will you use to intubate? On direct laryngoscopy, the patient had a Grade I view and intubation was accomplished quickly. You connect the patient to the anesthesia circuit without difficulty. Pulmonary compliance is poor and there is limited chest rise. End-tidal CO2=20 and wave capnogram is dampened. Upon auscultation there are very faint breath sounds bilaterally. 7. What is your differential diagnosis? The non-invasive blood pressure is now 52/30 and the heart rate is in the 140s from 90s. You recycle the cuff and the blood pressure is still 52/30. O2 sats are falling and are now in the 80s. 8. Does this change your differential? 9. What do you want to do? Do you need additional monitors? 10. Is there anything that you need to do differently because you are in the MRI suite? Where is emergency equipment in the MRI suite (code cart, MH cart, etc.)? The patient has been stabilized and you are ready to proceed with the MRI. 11. Are there any labs or studies that could be done to help with a definitive diagnosis on the cause of the previous event? The MRI finishes without any further events and the radiologist reads the scan as “normal”. 12. What would be your criteria to send this patient home? Does this differ from another patient coming for an outpatient MRI? 13. What information will be discussed with the family regarding the anesthetic? Anaphylaxis and Anesthesia Anaphylaxis was defined by the second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium as “…a serious allergic reaction that is rapid in onset and may cause death.” At one time non-IgE mediated reactions were termed “anaphylactoid”, but the European Academy of Allergology and Clinical Immunology recommended that this term no longer be used and that there is both Ig-E mediated and non-IgE mediated anaphylaxis. The latter term has not been uniformly accepted. Anaphylaxis during the perioperative period can be a challenging event. Since it is a clinical syndrome involving various organ systems, diagnosis can be delayed or missed. It is estimated that the incidence of anaphylaxis under anesthesia is 1:3,180 – 20,000. The highest incidence is with neuromuscular blocking agents (NMBAs) and occurs in 1 in 6,500 administrations (60% of anaphylaxis cases). After NMBAs, latex (12-16% of reactions) and antibiotics (8%) are the largest culprits. Cardiac arrest and fatalities secondary to anaphylaxis occur in 0.7- 10% of reactions. Believed underreporting accounts for the large ranges in incidence. Less frequently involved agents include: dyes, hypnotic agents, local anesthetics, opioids, colloids, aprotinin, protamine, chlorhexidine, and IV contrast agents. In children, the incidence of anaphylaxis is 1:7,700 where latex accounts for 76% of the reactions. The clinical features of anaphylaxis under anesthesia may include the cardiovascular system (tachycardia, bradycardia, arrhythmias, hypotension, cardiovascular collapse, and/or cardiac arrest), pulmonary system (bronchospasm), erythema, urticaria, and angioedema. A grading scale was described by Ring and Messmer (see TABLE 1). Grades I and II are not usually life-threatening. Grades III and IV are emergencies. Grades Clinical Signs I Cutaneous-mucous signs: erythema, urticaria with or without angioedema II Moderate multivisceral signs: cutaneous-mucous signs +/- hypotension +/- tachycardia +/- Dyspnea +/- GI disturbances III Life-threatening mono- or multivisceral signs: cardiovascular collapse, tachycardia, or bradycardia +/- cardiac dysrhythmia +/- bronchospasm +/- cutaneous-mucous signs +/- gastrointestinal disturbances IV Cardiac arrest Table One: Ring and Messmer Grading Scale for Anaphylaxis by Clinical Manifestations The patient’s sensitivity and route of administration may determine the severity of the reactions. Intravenous administration or mucous membrane exposure is likely to have the most severe reactions and faster onset whereas, rectal administration may take 15-30 minutes for onset of symptoms. Risk factors for anaphylaxis include: patients who have had a previous immediate life-threatening event that was not investigated; patients with risk factors for latex allergies (see below); patients with a history mastocytosis; and patients who are allergic to one of the drugs/products that will likely be used during an anesthetic. Treatment of anaphylaxis starts with removal of the offending agent. After that the following measures should be taken: (1) Call for help; (2) discontinue the anesthetic drugs when anaphylaxis occurs during induction; (3) maintain the airway with 100% oxygen, (4) in the case of a Grade III or IV reaction, give epinephrine early; (5) expand intravascular volume; (6) consider placing the patient in Trendelenburg position; and (7) speak with the surgeon about abbreviating or terminating the procedure. Of note, epinephrine is never indicated for Grade I reactions and only occasionally needed for Grade II reactions. A recent Danish study (Anesthesiology July 2011) concluded if you suspect anaphylaxis due to hemodynamic changes, you should administer epinephrine early. Although not statistically significantly different, the group given epinephrine early had a shorter post-event treatment course. Occasionally, epinephrine does not restore hemodynamics. This clinical syndrome has been named “anaphylactic shock refractory to catecholamines”. In these rare events, norepinephrine or glucagon should be used in patients on ß-blocker therapy and vasopressin used in others. Recently (2008), methylene blue was used to treat catecolamine and vasopressin-resistant anaphylaxis. Its interference with nitric oxide-mediated smooth muscle relaxation is believed to be the mechanism for working in this situation. If bronchospasm occurs, it should be treated with inhaled ß2 agonists. If bronchospasm occurs in the face of cardiovascular collapse, than IV epinephrine remains the first-line therapy. IV corticosteroids should be given early for their anti-inflammatory properties although effects may take up to 4-6 hours. H-1 and H-2 blockers are frequently given during anaphylaxis episodes although they have never been studied in placebo-controlled trials. Pretreatment (to prevent anaphylaxis) with corticosteroids and histamine receptor blockers remains controversial. Only IV contrast has shown consistently to be helped by pretreatment. The overall incidence is not decreased, but if anaphylaxis occurs in this setting, severity is reduced with pretreatment. Any allergic or anaphylactic reaction under anesthesia must be investigated. This should consist of three parts: (1) perioperative and postoperative testing to confirm the nature of the reaction, (2) identification of the offending agent (or possible cross-reactivity), and (3) providing recommendations for future anesthetics. Serum tryptase is the only blood test that should be drawn during the event (within 15 and 60 minutes in grade I and II reactions; within 30 minutes and 2 hours in Grade III and IV reactions) and at 24 hours after the event. This is elevated with mast cell degranulation and will be elevated in both anaphylaxis and anaphylactoid. In non-IgE reactions (anaphylactoid), the elevation will not be as pronounced. Absence of tryptase does not preclude a Grade I or II reaction and its elevation may be seen in underlying mastocytosis. Skin testing may be recommended, but these tests should be ordered by an allergist or immunologist. There are in vitro specific IgE assays, but these are less sensitive than skin testing. Latex Allergy Latex allergy as a medical entity started to be examined more carefully in the 1980s when a large number of case reports of latex anaphylaxis under general anesthesia were reported.
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