RevBrasAnestesiol.2017;67(4):422---425
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologia www.sba.com.brCLINICAL
INFORMATION
Anesthetic
management
of
late
pressure
angioedema
Inês
Furtado
∗,
Filipe
Linda,
Sílvia
Pica,
Marco
Monteiro
HospitalGarciadeOrta,DepartamentodeAnestesiologia,Almada,Portugal
Received1June2016;accepted12September2016 Availableonline30September2016
KEYWORDS
Angioedema; Pressure; Airway
Abstract
Backgroundandobjectives: Latepressureangioedemaisarareformofangioedemainwhich lightpressurestimuluscanleadtoedemaafter1---12h.Thisuncommonandunreportedentityis especiallyimportantinpatientswhoundergogeneralanesthesia,forwhomtheusualharmless supineposition,intravenouscatheterinsertion,standardmonitoring,airwaymanagementand ventilationcanleadtolifethreateningconsequencesasthetriggerisaphysicalstimulus.
Casereport: Inthisreport,wedescribeasuccessfulperioperativeanestheticmanagementof a30yearoldpatient,proposedforintra-ocularlensinsertion,withasevereformofthedisease withperi-oral,tongueandlimbedemapresentation.
Conclusion:Duetolackofqualityevidence,ourconductwas basedonthepathophysiology mechanismsofthesyndrome,histamineandpro-inflammatorycytokinesrelease,withspecial focusonacarefulperi-operativeassessmentandprophylaxis,minimizationofallthepossible pressurestimulus,especiallyintheairwaystructures,andastrictpost-operativemonitoring. ©2016SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
PALAVRAS-CHAVE
Angioedema; Pressão; Viaaérea
Manejoanestésicodeangioedemadepressãotardio
Resumo
Justificativaeobjetivos: Angioedemadepressãotardioéumaformararadeangioedemana qualumleveestímulodecompressãopodelevaraedemaapós1-12horas.Essaentidade inco-mumepoucorelatadaéespecialmenteimportanteempacientessubmetidosàanestesiageral, nosquaisahabitualposic¸ãosupinainofensiva,inserc¸ãointravenosadocateter,monitorac¸ão padrão,manejodasviasaéreaseventilac¸ãopodemlevaraconsequênciasfatais,poisogatilho éumestímulofísico.
∗Correspondingauthor.
E-mail:inesffurtado@hotmail.com(I.Furtado).
http://dx.doi.org/10.1016/j.bjane.2016.09.004
Anestheticmanagementoflatepressureangioedema 423
Relatodecaso: Nesterelato,descrevemosomanejoanestésicoperioperatóriobem-sucedido deumpacientede30anosdeidade,agendadoparainserc¸ãodelenteintraocular,comuma formagravedadoenc¸a,apresentandoedemaperioral,língualenosmembros.
Conclusão:Devidoàfaltadeevidênciasdequalidade,nossacondutatevecomobaseos mecan-ismos fisiopatológicos da síndrome, aliberac¸ão de histamina e citocinas pró-inflamatórias, comfocoespecialemumaavaliac¸ãocuidadosanoperioperatórioeprofilaxia,diminuic¸ãode todososestímuloscompressíveispossíveis,especialmentenasestruturasdasviasaéreas,eum acompanhamentorigorosonopós-operatório.
©2016SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigo OpenAccess sobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
LatePressureAngioedema(LPAE)isaninfrequententity cha-racterized by swelling of the skin and deep soft tissues, 1---12h after light pressure stimulus.1---3 Occasionally ery-thema,pain,pruritusandflu-likesymptomsandarthralgia coexist.EtiopathogenesisofLPAEisstillunknown,although the available evidence suggests the involvement of mast cells andof severalmediators other than histamine,such aspro-inflammatorycytokines.2ThemanagementofLPAEis complex,and prevention very difficult asthe only known trigger is physical stimulus wich is almost impossible to abolish.2,4
In a surgicalpatient non-invasivemanipulation suchas supine positioning on the surgical table, face mask ven-tilation, oro-tracheal tube insertion, arm tourniquet for intravenouscannulation, usuallyharmlessprocedures,can leadtoimportantcomplicationsinthesepatients.
Because only sparse and incomplete anesthetic mana-gementreportshavebeenaddressedintheliterature,our proceduresweretheresultofclinicaljudgment,according tothe pathophysiology of the disease and their potential clinicalimplications.5
Consent
for
publication
Thepatientreviewedthecasereportandgavewritten per-missiontotheauthorstopublishthereport.Alltheauthors describedinthecasereportparticipatedinthecareofthe patient.
Case
report
A 30 year old male, with a history of late pressure angioedema presented for elective bilateral intra-ocular lensinsertionduetoseveremyopia.
The patient reportedthebeginning of theangioedema symptoms 7 years ago. Since then symptoms occurred sporadically (3---4 times monthly) and were characterized onlyby edema,without erythema, pruritus,painor other systemic symptoms, usually 5h after stimulation with spontaneous resolution within hours. The edema was mainlyintongueandperi-oralregion,usuallytriggeredby light pressure(biting andmanual pressurewere themost
common),healsoreportedoccasionalfeetandhandedema. There was no history of anaphylaxis, urticaria, allergic reactiontofood,drugsorenvironmentalallergensor famil-iarhistoryofangioedema.Thepatienthadaregularfollow upwithanallergistandallthediagnostictestwerenegative, includingbloodcount,C4andC1inhibitorlevelsand func-tion(basalstatusandduring anattack).TSH,freeT4and athyroidautoantibodieslevelswereallwithinthenormal limits.
The patient also had a history of a gastro-esophageal refluxand gastritis.Hedidnottake anymedicationsona dailybasis.
Thepatienthadtwoprevioussurgeries:appendicectomy, 11yearagoperformedundergeneralanesthesiaand hernio-plasty, 8 year ago, performed with neuraxial anesthesia. There were no anesthetic complications with those pro-cedures; however, both occurred prior to the first LPAE symptoms.
Thepatientwasproposedtoabilateralintra-ocularlens insertion,ashortprocedure estimated tolast30min per-formedinsupineposition.
Atthepre-operativeanestheticappointmenttwoweeks beforethesurgery,hisphysicalexaminationwas unremark-able.
WeusedtheregularmethodofarmtourniquetforIV20G cannulationin the surgery morning.One hour before the surgery10mgof dexametasone,10mgof metoclopramide and50mgofranitidinewereadministratedintravenously.In theoperatingroomthenursesandsurgeonswerealladvised inordertominimizeallthepossiblepressurestimulus.
Weusedstandardmonitoring,withextracareintheECG electrodesandoxymeterplacement.Wechoosetomeasure thearterial pressureevery15min andwhen any hemody-namicalterationwassuspected.
We performed a rapid sequence induction with mida-zolam (15mcg.kg−1); fentanyl (2mcg.kg−1), propofol
(2mg.kg−1) and rocuronium (1mg.kg−1). The induction
phaseoccurreduneventfully.
424 I.Furtadoetal.
Thepatientwasventilatedinavolumecontrolled modal-ity,withatidalvolumeof7mL.kg−1witha6mmH2OPEEP,
andtherewerenotanycomplicationsorhighairway pres-sures.
Atthebeginningoftheprocedurewealsoadministered hidrocrotisone3mg.kg−1.Attheendweusedparacetamol
1g,ondansetrom4mgandsugamadex2mg.kg−1,aswehad
aTOFratioof22%.
We used a special pressure relieving mattress and all peripheralpressureareaswerepadded.
Theorotraquealtubewasextra-paddedandthesurgeon wasadvisedfortheextracareregardingpatienthead han-dling.
The emergence elapsed without any complications, and extubation was performed with minimal oral suction manoeuversandwithvigilanceuntilcompleteawareness.
As the patientwasa doctor hebelieved hecould give warningbeforepotentialairwayedema. He stayedat the postanestheticcareunitfor5hwithoutanyhemodynamic instability, airway edema or any other symptoms; he did not complain of pain and wasalways awake and cooper-ative. During this period there were no signs of edema or erythema in the mouth or in any other location. He was transferred to the hospital inpatient unit were he stayed for another 3h before he was discharged home by the surgeon. The next hours at home were unevent-ful.
Discussion
Despite itsrare incidence, in a surgical patient LPAE can haveseriousimplications.Evensmallstimulus,thatusually goesunnoticed,cancauseseverecomplications.Anesthetic peri-operative optimization can be challenging but it can preventseriouseventsinperioperativeperiod.
For a safe perioperative management first of all it is importanttoknowthetriggerstimulusinordertoavoidor minimizethem,becausejustlyinginthesurgicaltablecan beatriggerinthesepatients.
Thepatienthistorycouldbecompatiblewithotherforms ofedema,suchashereditaryangioedema,auto-immune dis-easeorassociatedwithsomespecificcausativefactorsuch asenvironmentalallergen. Thosediagnosiswould ledtoa verydifferentapproach,asthereisn’tthedirect interfer-enceofhistamine.AsC4andC1inhibitorlevelsandfunction werenormal,therewerenofamiliarhistoryofedema,there wasnohistoryofanaphylaxisandauto-immunetestswere negative,itwasassumedthattheonlytriggerwasphysical ---pressure.Astheunderlyingphysiopathologicalmechanism ofLPAEishistamineandpro-inflamatorycytocinesrelease, weactedaccordingtoit.
Wechoseageneralanesthesia,becausethelocoregional techniques, as retro or peribulbar blocks, could create an intra orbitary pressure increment that could trig-ger angioedema with devastating consequences for the intra orbitary organ content, so this was not a suitable option.
Our first concern was the IV cannulation and arterial pressure monitoring. Despite our concern about the arm tourniquet pressure for Intravenous (IV) cannulation, the patienthada recentuneventfulblood specimencollected
so we used the regular method of arm tourniquet for IV 20G cannulation in the surgery morning inspite of ultra-soundguidedcannulation,thatwouldhavebeenanoptimal option.
Thepatientexplainedthatbloodpressuremeasurements didnot causeproblems previously, andasthis wasa very shortprocedure,weoptedfortheregulartechniques with-out the ultrasound guidance despite continuous arterial pressure monitoring with an arterial line was the safest optiontoavoidsphygomanometeruse.
Theoretically pre-medication with corticoids and anti-histaminics seems important to minimize unwanted side effects,soweuseddexamethasone,hidrocrotisoneand ran-itidethathadadoubleroleasgastricacidityinhibitorand angioedemaprophylaxis.
The airway management is the most delicate subject in this condition. Edema in the airway can be impossible to resolve or even to bypass and can lead to important morbidity orevendeath. Intensepressure stimulusduring laryngoscopy, intubation and cuff inflation andface mask ventilation should be avoided, or when that is not possi-ble, adjusted in a way that minimal pressure is applied. Rapid sequence induction seems to be a safer option in order to avoid hand and mask pressure in the face, lips andmandibula.ForlaryngoscopyweusedanAirtraqdevice withonlygentlepressureinthelaryngealstructuresto min-imizethepressure andtrauma ofthe laryncoscopicblade inthevaleculeanreduce theedema risk.Weuseda rein-forcedtrachealtubebecauseofitspliabilityandatraumatic characteristics.Asourpatienthadesophagealrefluxandan uncuffedtubewasnotanoptionweusedacuffedtube,but despite thelowpressurethispressurepoint wasourmain concern.
The post-anesthetic care in the PACU and inpatient unit is also an important period and the communication between anesthesit and other staff is essential to iden-tify any problemin advance. An extended PACUstay is a safe measurement as an emergency management is usu-ally faster as staff is well trained to deal with airway emergentcomplicationsandtechnicalresourcesareeasily available.
In conclusion there were several challenges and some technical improvisation was required due to lake of evi-dence. Surgical patients with LPAE can have serious post-operative complications but careful peri-operative assessment with minimization of all the possible pres-sure stimulus, especially in the airway structures, can avoid morbidity and allows an uneventful post-operative period.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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