Latex anaphylaxis causing heart block: role of ranitidine

Abstract

FRCPCPurpose: Treatment with H 2 receptor antagonists may cause the heart to be more susceptible to atrioventricular conduction delay when exposed to an overwhelming insult by histamine released during an anaphylactic reaction. We present the case of a woman, pretreated with ranitidine, who developed 3:1 heart block secondary to latex anaphylaxis. We propose that H 2 antagonist premedication alone in patients susceptible to anaphylaxis increases their risk of heart block. Clinical Features: A 38 yr old obese woman with cervical cancer presented for a radical hysterectomy. Systems review yielded a history of sleep apnea, orthopnea, gastroesophageal reflux, and sciatica. Medications included preoperative ranitidine, 150 mg. There was no history of atopy or allergy. Following general anesthesia induction, at the onset of the surgical procedure the patient developed a severe anaphylactic reaction which was heralded by the onset of 3:1 heart block, with decreases in SpO 2, PETCO2 and a decrease in systolic blood pressure to 45 mmHg. This was diagnosed as a possible latex reaction and treated using epinephrine boluses and infusion, fluids, 50 mg diphenhydramine, 50 mg ranitidine and I00 mg hydrocortisone. Following a 48 hr stay in the ICU the patient made an uneventful recovery. Allergy testing with intradermal latex injection and increased plasma tryptase levels confirmed a latex anaphylaxis. Conclusion: The use of H 2 antagonists alone as a prophylaxis for gastroesophageal reflux may increase the risk of heart block in patients who develop anaphylaxis.Objectif: Un traitement aux antagonistes des r&epteurs d'H 2 peut entraTner une plus grande susceptibilitE du coeur au retard de conduction atrioventriculaire lorsqu'expos~ ~ une importante agression par la liberation d'histamine pendant une reaction anaphylactique. Voici le cas d'une femme, prEtraitfie avec de la ranitidine, qui a dEveloppE un bloc cardiaque 3:1 secondaire ~ ranaphylaxie au latex. Nous croyons que, chez les patients susceptibles d'anaphylaxie, la seule pr~mEdication aux antagonistes de rH 2 augmente le risque de bloc cardiaque. ~l(;mcnts cfiniques : Une femme de 38 ans, obese, atteinte d'un cancer du col de l'ut&us, s'est pr&ent~e pour une hyst&ectomie radicale. Lanamn&e a r~v~l~ : apnEe du sommeil, orthopn6e, reflux gastro-oesophagien, sciatalgie, mais pas d'ant&~dents d'atopie ou d'allergie. La medication comprenait 150 mg de ranitidine prEop&a-toire. Apr~s l'induction de l'anesth&ie gEn&ale, au d~but de l'intervention, la patiente a dEvelopp~ une r~action anaphylactique sEvEre annoncEe par la survenue d'un bloc cardiaque 3

Cataract surgery for natural rubber latex allergic patients

“…Latex allergy is now seen by some anaesthetists as a major risk factor to safe general anaesthesia because of a lack of awareness among healthcare workers, the lack of screening facilities for the condition during preassessment, and the potential for unpredictable severe anaphylactic reactions. 66,8,9 In addition to severe anaphylaxis, latex also produces milder problems, similar to those experienced by healthcare workers, such as asthma, rhinoconjunctivitis and irritant/allergic eczema.…”

“…Consequently, much of the current literature regarding the clinical significance of NRL allergy originates from the subspecialties involved in their care, particularly anaesthetics, intensive therapy unit (ITU) nursing and orthopaedics. [5][6][7][8][9][10][11] In addition to high-risk patient groups, there is also an increased incidence of NRL-related allergic reactions and NRL hypersensitivity seen in healthcare workers, for example, dentists, operating nursing staff, accident and emergency staff, [12][13][14] and this is thought to be due to increased exposure to NRL allergens within the work environment. There have been several controlled studies to examine the link between NRL allergy and the amount of NRL exposure amongst healthcare workers.…”

“…A prevalence estimate by a particular researcher depends very much on the definition of NRL-related allergy and the systems used for confirming the diagnosis by that researcher. These vary from looking for anti-NRL IgE antibodies in serum (1% in operating staff, 24 5.4-7.6% in blood donors, 25 8.6% in general paediatric population, and 17.3% in high-risk children 26 ), skin patch testing and skin prick testing (11% in healthcare workers 27 ), to screening questionnaires (up to 21.8% in healthcare workers 28 ). Many estimates of prevalence are based on the number of test positives in that population sampled and not on whether there is actual evidence of clinical allergy.…”

The Human Heart As a Shock Organ in Anaphylaxis

“…Interestingly, it has been reported that premedication with an H 2 receptor antagonist increases the risk of heart block in patients who develop anaphylaxis [54].…”

Transient third-degree AV block following sugammadex

“…Animal study and several clinical reports suggest that allergic reactions are the possible cause of AVB [2,3]. Considering the allergic reaction to sugammadex, we should have checked plasma level of histamine and tryptase.…”