What Happens When Your Patient Experiences Anaphylaxis in the OR?

My last case of the day began like all the others. The anesthesia team and I performed the anesthesia time out and confirmed the patient’s allergies. While preparing her for induction, we informed her of what we were doing and why and chatted about her grandchildren. After induction, we performed all the usual tasks of positioning, prepping, and counting, but as the scrub nurse began draping, the patient’s initial hypertension gave way to pressures reading 90/50, then 75/23, and she became bradycardic.

The anesthesiologist and certified registered nurse anesthetist showed no signs of distress. They calmly managed her with a bolus of epinephrine and changed her position to Trendelenburg, which is a common intervention for hypotension because it may increase brain perfusion.¹ Standing nearby and ready to assist, the surgeon, scrub nurse, and I watched the patient’s vital signs on the screen. As the RN circulator, I observed the anesthesia team’s reactions with each new blood pressure reading. I offered to call for additional help, but they gently declined. The patient’s chest was obstructed by drapes as they tried to visualize it, so I removed them. I also turned off the music.

The patient’s pale skin showed erythema and as l looked closely at her mouth, I thought I saw angioedema, so I alerted the anesthesia team. None of us could remember what her mouth looked like at induction, and we realized how mask requirements interfere with preoperative facial assessment. Even so, we assumed her puffy lips were a result of edema.

The anesthesia team continued pushing epinephrine, phenylephrine, calcium chloride, diphenhydramine, and ephedrine, yet her pressure resisted and remained low. Finally, her pressure rebounded, and the anesthetics were turned off. The surgeon cancelled the case, and the anesthesiologist admitted her to the surgical intensive care unit overnight.

Once the anesthesia team had stabilized her, she emerged and was coherent as the team explained what happened. She was concerned we had not completed her surgical procedure. We remained with her and calmly reassured her that she would undergo her procedure at a later date, but that her immediate safety was our larger concern. Since she was still groggy from the anesthesia and diphenhydramine, we had to explain what happened several times while waiting for an intensive care unit bed.

Lessons

Anaphylaxis is a rare life-threatening acute systemic allergic reaction that is not easily detected in the anesthetized patient; anesthesiologists likely see one event within a 5- to 10-year span.² This event was the first I had seen in just over a decade in the OR. Fortunately, I had an amazing team that knew how to manage this occurrence, and I knew my own role within the situation, which helped maintain a calm, quiet environment.

The allergy trigger cannot be confirmed without testing.³ Pharmacologic drugs are the second most common allergy trigger.³ Nothing in this patient’s medical history or minimal allergy list suggested a potential allergy to cefazolin, but the team assumed the antibiotic triggered her immunologic reaction since it occurred within minutes of administration.

Angioedema is one of the most common early signs of anaphylaxis, occurring in 88% of cases.³ Hypotension is present in 33% of cases and occurs within minutes or hours of exposure.³ Since the patient presented both these signs and other possibilities were ruled out, the team determined she was likely experiencing anaphylaxis. Epinephrine is the first-line treatment for anaphylaxis, but corticosteroids and diphenhydramine also may be administered following epinephrine.³

When an anaphylactic reaction occurs, it is essential to remain calm and to create a quiet environment, including turning off the music. It also is essential to know which medications, such as epinephrine, and interventions, such as Trendelenburg and removing suspected allergy triggers, can help mitigate the allergic response. Participating in simulated scenarios and reading peer-reviewed published articles on evidence-based practices are a few ways to learn to manage emergencies like anaphylaxis.

As an OR nurse, you can help when a patient experiences anaphylaxis by assisting the team as you deem necessary, such as by offering to seek more assistance or removing drapes to allow for better visualization (as I did with this patient), or if not present in the room, retrieving a crash cart since cardiac arrest is a risk in these patients.² It also is important to continually assess the patient. Assessing the anesthetized patient is difficult, but evaluating vital signs and skin changes, such as angioedema, erythema, and hives, can help you identify physical indications of anaphylaxis.² (It should be noted that if a patient with a latex allergy experiences an anaphylactic reaction, it will be important to first double check for any potential exposures to latex, such as a urinary foley catheter that contains latex, and immediately remove those items from the patient.)

References

1. Shammas A, Clark AP. Trendelenburg positioning to treat acute hypotension: helpful or harmful? Clin Nurse Spec. 2007;21(4):181-187.
2. Gouel-Cheron A, Harpan A, Mertes PM, Longrois D. Management of anaphylactic shock in the operating room. Presse Med. 2016;45(9):774-783.
3. Lieberman PL. Recognition and first-line treatment of anaphylaxis. Am J Med. 2014;127(1 suppl):S6-S11.
   

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