Anaphylactic shock in a patient with severe aortic stenosis treated with adrenaline and landiolol for circulatory management

Abstract

Rationale: We present the first case of a patient with severe aortic stenosis who developed anaphylactic shock and was successfully treated with adrenaline and landiolol, a highly selective β1-receptor blocker, to prevent disruption of the myocardial oxygen supply–demand balance caused by tachycardia. Patient concerns: An 86-year-old woman was scheduled for simultaneous anterior–posterior fixation for a burst fracture of the 12th thoracic vertebra; 200 mg sugammadex, a neuromuscular blocking agent antagonist, was administered postoperatively, and she was extubated without complications. However, 6 min after extubation, her blood pressure decreased abruptly to 55/29 mm Hg, and her heart rate increased to 78 bpm. Then, we intervened with fluid loading, an increased dose of noradrenaline, and phenylephrine administration. However, her blood pressure did not increase. Diagnoses: A general observation revealed urticaria on the lower leg; thus, we suspected anaphylactic shock due to sugammadex administration. Interventions: We carefully administered 2 doses of 0.05 mg adrenaline and simultaneously administered landiolol at 60 μg/kg/min to suppress adrenaline-induced tachycardia. Adrenaline administration resulted in a rapid increase in blood pressure to 103/66 mm Hg and a maximum heart rate of 100 bpm, suppressing excessive tachycardia. Outcomes: The patient's general condition was stable after the intervention, and circulatory agonists could be discontinued the following day. She was discharged from the intensive care unit on the fourth postoperative day. Lessons: Landiolol may help control the heart rate of patients with aortic stenosis and anaphylactic shock. The combined use of landiolol and adrenaline may improve patient outcomes; however, their efficacy and risks must be evaluated by studying additional cases.

Refractory cardiac arrest caused by type I Kounis syndrome treated with adrenaline and nicorandil: A case report

“…In addition, attention should be given to the dosage and method of administration to minimize the adverse effects of adrenaline. [19,20] Finally, if adrenaline and other vasopressors prove to be ineffective, extracorporeal cardiopulmonary resuscitation should be considered; however, this is an invasive technique and should be avoided if possible.…”

“…[17] However, adrenaline may also exacerbates myocardial ischemia by further reducing coronary blood flow that is already impaired in Kounis syndrome due to factors such as coronary vasospasm, thrombus formation, and tachycardia. [1,8,18,19] Noradrenaline, vasopressin, and glucagon can be used in addition to adrenaline for treatment-resistant anaphylactic shock, [4,7,16] but there is no evidence to support their use in the absence of adrenaline. Therefore, we believe that, in cases of fatal anaphylaxis and anaphylactic shock, including Kounis syndrome, the use of adrenaline should not be avoided.…”