Anaesthesia, 2010, 65, pages 82–93 Correspondence

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anaphylaxis management per the Anaphylaxis under anaesthesia is rare, ated with Anaesthesia. London, UK:
Association of Anaesthetists of Great but in 60% of cases neuromuscular AAGBI, 2003.
Britain and Ireland guidelines [1]. Bron- blocking drugs are the causative agents 3 Laxenaire MC, Mertes PM; Groupe
chospasm, the predominant clinical fea- and in only 15% are antibiotics at fault [1]. d’Etudes des Réactions Anaphylac-
ture, was so severe it necessitated Our assumption that cefuroxime rather toı̈des Peranesthésiques. Anaphylaxis
disconnection of the breathing circuit than vecuronium was the precipitant was during anaesthesia. Results of a two-
and manual compression of the chest therefore likely to have been incorrect. year survey in France. British Journal of
wall to facilitate exhalation. Suxamethonium is the most likely of the Anaesthesia 2001; 87: 549–58.
Following a positive response to neuromuscular blockers to cause ana-
treatment, a decision to proceed with phylaxis, followed by rocuronium [3].
surgery was made together with the Twenty-five percent of those surveyed Subcostal transversus
neurosurgeons. Despite an increased failed to rank suxamethonium as the abdominis plane block
risk of coagulopathy associated with highest-risk agent and 40% thought
anaphylaxis, the team felt that the need rocuronium to be low-risk. Whether We would like to describe a case in
to preserve hand function, which was sugammadex will increase rocuronium’s which we successfully used a subcostal
being compromised by the tumour, use waits to be seen, but clearly anaes- transversus abdominis plane block in a
justified the fact that we proceeded to thetists underrate its allergic potential. frail elderly patient requiring a defunc-
surgery. Surgery was uneventful. The Like the anaesthetists in the case above, tioning ileostomy. The patient had very
patient’s trachea was extubated success- most respondents regarded vecuronium limited exercise tolerance and presented
fully the following morning. as the safest neuromuscular blocking drug on the emergency list. Following a CT
Tryptase and complement levels (38%) or ranked it 5th or lower, out of 7 scan of the abdomen, a diagnosis of small
were all normal; however, this doesn’t agents (65%). This is not in accordance bowel obstruction was made, with a
rule out anaphylaxis [1]. Skin prick with the literature which gives vecuro- stricture in the area of the ileocaecal
testing for neuromuscular blockers nium medium risk [3]. Even though valve. The patient was warfarinised for
cefuroxime, propofol, lidocaine, remif- cis-atracurium was regarded as the safest atrial fibrillation and had a pre-operative
entanil and latex were performed, all of agent by 27% it is only used by 2% of INR of > 10. The surgeons wished to
which were subsequently negative. respondents. perform a defunctioning ileostomy using
With hindsight, we suggest that move- This incident highlights how the an incision in the right upper quadrant.
ment of the tracheal tube during deleterious effects of gas trapping during This patient was high-risk due to her
insertion of the throat pack precipitated bronchospasm can masquerade as significantly limited physiological
bronchospasm, and the high inflation anaphylaxis. In addition, our survey reserve. After discussion, she declined
pressures with auto-PEEP resulted in suggests that anaesthetists are poorly the option of postoperative admission to
reduced venous return, hypotension informed regarding the anaphylactic the Intensive Care Unit (ICU). Tho-
and cardiovascular collapse, thus potential of neuromuscular blocking racic epidural placement was unsuitable
mimicking anaphylaxis. drugs, and that the choice of the latter due to the high INR. It was agreed
We conducted an internal survey of is not guided by concerns over anaphy- with the patient that the procedure
all anaesthetists in the Leeds General lactic risk. The administration of anti- could be performed under local anaes-
Infirmary asking them about the timing biotics, at induction, is at variance with thesia and sedation, and if this was
of administration of intravenous anti- both ideal practice and guidance. unsuccessful, she would be for conser-
biotics in theatre and also to rank the vative management only. We consid-
A. Kant ered using a transversus abdominis plane
anaphylactic risk of various neuro-
J. McKinlay block [1, 2] to provide analgesia; how-
muscular blockers. One hundred
Leeds General Infirmary ever, if conventionally performed, it
responded (an 83% response rate).
Leeds UK would only provide a reliable block for
Although 25% of respondents believed
E-mail: [email protected] incisions to the level of T8. Following a
antibiotics should be given more than
30 min before induction, only 15% literature search an alternative tech-
administer them before and 5% give References nique described by Hebbard [3, 4], the
them with induction agents. Previously, 1 The Association of Anaesthetists of subcostal transversus abdominis plane
the Association of Anaesthetists of Great Great Britain and Ireland. Guidelines – block, used to provide effective analge-
Britain and Ireland has recommended Suspected Anaphylactic Reactions Associ- sia for a cholecystectomy incision, was
that antibiotic administration should be ated with Anaesthesia. 2009. http:// chosen as a potential solution.
separated from induction [2], thereby aagbi.org/publications/guidelines/ Following correction of her INR with
allowing the normal haemodynamic docs/anaphylaxis_2009.pdf (accessed vitamin K and 1500 IU prothrombin
changes at induction of anaesthesia to 11 ⁄ 10 ⁄ 09). complex concentrate, we performed the
resolve, yet over 70% of respondents 2 The Association of Anaesthetists of subcostal transversus abdominis plane
administer antibiotics within 10 min of Great Britain and Ireland. Guidelines – block following Hebbard’s description,
induction. Suspected Anaphylactic Reactions Associ- under ultrasound [5] (Fig 1). In contrast

 2009 The Association of Anaesthetists of Great Britain and Ireland 91

Correspondence Anaesthesia, 2010, 65, pages 82–93
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ageing. The definitive treatment for

severe aortic stenosis is valve replace-
ment, which improves symptoms and
prognosis. Age itself is not a contrain-
dication to surgery; operative mortality
is low but is higher in patients with
comorbid conditions. Non-operative
treatment of aortic stenosis carries a
poor prognosis.
Despite the favourable results of
surgical aortic valve replacement, many
patients with severe, symptomatic aortic
stenosis are not offered surgery. The
Euro Heart Survey found that a deci-
sion not to operate was taken in 33% of
216 patients aged 75 years and over
with severe, symptomatic aortic stenosis
[2]. McBrien et al. did not report the
number of patients with aortic stenosis
Figure 1 Needle and probe position for ultrasound guided subcostal transversus
who progressed to valve replacement
abdominis plane block (Diagram kindly provided by Dr P Hebbard). during the follow-up period, which
would be an interesting addition to
to the more familiar transversus abdo- abdominis plane block after abdominal their study.
minis plane block the subcostal block is surgery: a prospective randomized The new evolving technique of
performed at the costal margin with controlled trial. Anesthesia and Analgesia transcatheter aortic valve implantation
hydro-dissection of the appropriate plane 2007; 104: 193–7. provides an alternative, less invasive
caudally. We used 20 ml 0.5% levobup- 3 Hebbard P, Fujiwara Y, Shibata Y, treatment for aortic stenosis, avoiding
ivicaine and the block was confirmed Royse C. Ultrasound-guided transver- the need for median sternotomy and
with loss of sensation to ice. A low-dose sus abdominis plane (TAP) block. cardiopulmonary bypass [3]. The pro-
remifentanil infusion (0.1 lg.kg.min)1) Anaesthesia and Intensive Care 2007; 35: cedure is safe and effective in the short-
was commenced to cover visceral stim- 616–7. term; long-term outcome data are
ulation and the rate was gradually 4 Tran TM, Ivanusic JJ, Hebbard P, emerging [4]. High-risk patients with
reduced to 0.02 lg.kg.min)1 during Barrington MJ. Determination of concomitant illnesses not suitable for
the procedure. The patient was comfort- spread of injectate after ultrasound- surgical aortic valve replacement may
able throughout and we are confident the guided transversus abdominis plane now be offered transcatheter aortic
block provided sufficient analgesia for block: a cadaveric study. British Journal valve implantation. Therefore, as the
the large initial incision and dissection to of Anaesthesia 2009; 102: techniques and indications for less
the small bowel. The patient made an 123–7. invasive treatment of aortic stenosis
excellent recovery. 5 Hebbard P. http://usra.ca/UIA/ continue to evolve, the timely diagnosis
Getfile.php/id=30 (accessed of the disease will become even more
K. O’Connor important.
09 ⁄ 09 ⁄ 09).
C. Renfrew McBrien et al. rightly call for ade-
Ulster Hospital quately resourced echocardiography
Belfast, UK Peri-operative echocardio- services so that pre-operative echo-
E-mail: [email protected] graphic diagnosis of aortic cardiography in hip fracture patients
stenosis with suspected aortic stenosis does not
References delay operative fracture fixation. Delay-
1 Carney J, McDonnell JG, Ochana A, McBrien et al. [1] recently analysed the ing surgery beyond 48 h after admission
Bhinder R, Laffey JG. The transversus management and outcome of 272 with hip fracture may increase 30-day
abdominis plane block provides effec- patients identified with previously and 1 year all-cause mortality [5]. We
tive postoperative analgesia in patients undiagnosed aortic stenosis before hip suggest that valvular intervention in hip
undergoing total abdominal hysterec- fracture surgery. We congratulate the fracture patients with severe aortic
tomy. Anesthesia and Analgesia 2008; authors on reporting this large series of stenosis should not delay surgery and is
107: 2056–60. patients with aortic stenosis undergoing optimally performed after hip fracture
2 McDonnell JG, O’Donnell B, Curley noncardiac surgery. fixation.
G, Heffernan A, Power C, Laffey JG. Degenerative aortic valve disease is We support McBrien et al. and rec-
The analgesic efficacy of transversus common and closely correlated with ommend early identification of aortic

92  2009 The Association of Anaesthetists of Great Britain and Ireland