Aspirin/lisinopril/muscle relaxants
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Angioedema: case report A 65-year-old woman developed angioedema (AE) during treatment with lisinopril (for hypertension), aspirin and unspecified muscle relaxant [dosages and routes not stated]. The woman presented for coronary artery bypass grafting. Her medical history was significant for hypertension, atrial fibrillation, type II diabetes, hypothyroidism, obesity and hyperlipidaemia. Her pre-operative medications included metoprolol and aspirin, which were continued until morning of the surgery. She also had been receiving lisinopril (an angiotensin converting enzyme inhibitor, ACEi), metformin and rivaroxaban, which were also discontinued 48 hours prior to the surgery. She underwent placement of endotracheal tube (ETT) under general anaesthesia. Anaesthetic management included inhalational anaesthesia, unspecified benzodiazepines, unspecified narcotic and unspecified muscle relaxant. As per divisional protocol, she received a total of 30g of aminocaproic acid throughout the surgery for prophylaxis of angioedema (off-label therapy). The coronary artery bypass grafting surgery was uneventful. After stopping cardiopulmonary bypass, she was haemodynamically stable, and she started receiving norepinephrine, epinephrine and IV fluids. After removing the surgical drapes, a non-urticarial rash was observed across the upper thorax. Her tongue (protruding from the mouth) and lips were found to be severely swollen. Hence, an ETT was placed. Her pulmonary functions were however stable, and obstruction of airway passage was not observed. The woman was treated with dexamethasone, ranitidine and diphenhydramine for a presumed allergic reaction. Her back and head were elevated to decrease the swelling. Thereafter, she was transferred to the ICU, and her pulmonary and cardiovascular functions remained stable. Within 24 hours of ICU admission, norepinephrine and epinephrine infusions were stopped. Medications known to cause angioedema (i.e. lisinopril, non-steroidal anti-inflammatory drugs and muscle relaxants) were stopped or avoided thereafter. Diphenhydramine, dexamethasone and ranitidine were continued every 8 hours. After 48 hours, she improved, but the tongue swelling persisted. Histamine level was 50 ng/mL and tryptase level was 8 ng/mL. A C1 serine esterase inhibitor (C1-INH) level was 41 mg/dL. Based on the findings, she was diagnosed with bradykinin-related AE, which was thought to be related to lisinopril, aspirin and unspecified muscle relaxant use [time to reaction onset not stated]. With the expectation of resolution of swelling in 48–72 hours, no additional therapies were administered. Throughout her postoperative course, pulmonary and cardiovascular functions remained stable with intact renal, hepatic and neurocognitive functions. On postoperative day (POD) 7, her tongue swelling persisted, and no leak was noted around the deflated ETT. Ear, nose, and throat was consulted for potential tracheostomy. Thereafter, she received unspecified complement-C1 inhibitor protein 20U/kg [Berinert; off-label use]. Within
