Atropine/antihypotensives/indocyanine green
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Kim M, et al. Anaphylactic Shock After Indocyanine Green Video Angiography During Cerebrovascular Surgery. World Neurosurgery 133: 74-79, Jan 2020. Available from: URL: http://doi.org/10.1016/j.wneu.2019.09.135 - South Korea 803435063
Anaphylactic shock and lack of efficacy: 2 case reports A case series described a 69-year-old woman and a 58-yearold woman, who developed anaphylactic shock following administration of indocyanine green (a fluorescent dye) for video angiography monitoring during a cerebrovascular surgery in South Korea. Additionally, the 69-year-old woman exhibited lack of efficacy to atropine, epinephrine and phenylephrine for life-threatening hypotension during the anaphylactic shock [not all dosages and routes stated]. Patient 1: A 69-year-old woman, who had an unruptured intracranial aneurysm (IA), at the origin of the posterior communicating artery, underwent craniotomy and clipping of the IA. During the surgery, she received various medications. After uneventful surgical exposure and initial aneurysm clip placement, she received indocyanine green injection for video angiography monitoring. The injection of indocyanine green 25mg was diluted in 20mL of water [sterile water], which was administered through the central venous catheter. The bispectral index was maintained within the normal range. Indocyanine green-video angiography after clip placement revealed complete obliteration of the aneurysm. Within 5 minutes after the injection, her BP had suddenly dropped to 50/30mm Hg, and HR had rapidly changed to asystole. The surgical procedure was stopped immediately, and the drapes (except for those in the open craniotomy field) were removed to allow for prompt inspection of the chest, extremities and abdomen. The chest was clear to auscultation, but a rash-like skin lesion was noted on the abdomen and extremities. Immediately, chest compression was initiated with infusions of atropine 0.5mg, epinephrine 1mg and phenylephrine 100mg due to the life-threatening hypotension. Dexamethasone was also administered due to suspected an anaphylactoid reaction. Blood tests revealed an elevated serum tryptase level, suggesting anaphylactic reaction. Despite atropine, epinephrine and phenylephrine therapy, her BP markedly decreased, requiring chest compression for 3 minutes. Within 10 minutes after the initiation of the chest compressions, her BP had gradually recovered. She remained stable without further unusual events. On postoperative day 8, she was discharged without any other complications. On postoperative day 14, a skin prick test demonstrated positive result for indocyanine green, but negative for rocuronium bromide. Indocyanine green-induced anaphylactic shock was thus confirmed based on the clinical picture and investigations. Patient 2: A 58-year-old woman, who had an unruptured anterior communicating artery aneurysm, underwent clipping surgery. She was on simvastatin for hyperlipidaemia. She informed that previously (6 years earlier) she had a mild allergic reaction to unspecified contrast medi
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