Transcript SBH Journal Club Angioneurotic oedema and ACE inhibitors

Peter Sherren
NOT EVERY SWOLLEN FACE IS
ANAPHYLAXIS
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In 1990, the Association of Anaesthetists of Great Britain and
Ireland (AAGBI) published its first report on suspected
anaphylactic reactions associated with anaesthesia.
The reported suspected that, between 1995-2001, anaphylactic
reactions related to anaesthesia in the UK averaged 55 per year,
compared with 319 for all drugs1.
10% of anaesthetic reports were of fatalities compared with
3.7% for all drugs reported1.
The understandable concentration on anaphylaxis within
anaesthesia means that the knowledge of differential diagnoses
and therapeutic options may be limited.
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66 yr-old Afro-Caribbean
lady
Htn, DM, IHD and PPM
05.00 Sudden onset tongue
swelling and DIB
Called to DGH ED 06.15
Dramatic angioedema+,
drooling++, stridor, poor
vocalisation, agitated, SpO2
~92% FiO2 0.85 FM. CVS
stable
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MP V?
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Unexpected complication of treatment.
Unresponsive to steroids/anti-histamines/adrenaline.
ODP transported difficult airway trolley to resus.
Surgical Spr not happy/competent to perform emergency awake
trache.
18g cannula cricothyroidotomy performed pre-induction
uneventfully.
RSI, Grade III/IV (oedematous, distorted anatomy) view with
McCoy.
GEB sited 3rd pass.
Unable to pass 7.0 coett, 6.0 passed with difficulty, minimal leak
with no cuff deflated.
No issues ventilating.
Progression of angioedema post intubation.
10 day ICU admission, discharged to ward neurologically intact
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Out of hours communication/mobilisation of staff
and equipment outside of theatres.
Familiarity with, and applied use of equipment on a
well-stocked (theatre) difficult airway trolley.
Flexible use of DAS algorithm.
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Inadequate difficult airway trolley in ED.
Rail-roading size 6.0 coett over 15F bougie is
fiddly. Any smaller would have required a
CHANGE of bougie for a 10F.
Retrospectively, the needle cricothyroidotomy was
unnecessary, exposing already difficult airway to
potential trauma.
General surgical training inadequate?
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Causes of angioneurotic oedema
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Idiopathic- large proportion.
Mast cell related/anaphylaxis.
Hereditory (HAE) I and II- C1 inhibitor deficiency or dysfunction.
Acquired- immunosuppression and lymphoproliferative disorders.
Drug related- Aspirin/NSAIDS, ACE, opiates, abx.
ACE inhibitors related angioneurotic oedema2,3:
Now most common exogenous cause of angioedema seen.
Can occur any time from initiation through to 10 years into treatment.
0.1-0.5% of those receiving the drug.
Usually has no associated urticaria.
Due to increased bradykinin levels because kinin degradation is inhibited.
Can cause dramatic swelling of tongue, pharynx, or larynx- Secure airway
early.
 Deaths related to AIRWAY, no reported deaths from primary CVS collapse.
 Some response to Adrenaline and minimal to steroids and anti-histamines.
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In angioneurotic oedema (like burns):
• Use of size 10F bougie
• Use of uncut COETT
• Range of sizes of COETT ready for use
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Potential unique use of the Melker vs other large
bore cricothyroidotomy kit
Improvement/standardisation of difficult airway
trolley in ED
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Choice of large bore cricothyroidotomy kit?
• CUFFED seldinger vs PCK vs Quicktrach II
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Place for selected pre-emptive cannula
cricothyroidotomy and later use of Melker?
1.
AAGBI Working party. SUSPECTED ANAPHYLACTIC
REACTIONS ASSOCIATED WITH ANAESTHESIA.
AAGBI Revised Edition 2003. www.aagbi.org
2.
Adebayo PB, Alebiosu OC. ACE-I induced angioedema: a
case report and review of literature. Cases J. 2009 Jul
27;2:7181.
3.
Cupido C, Rayner B. Life-threatening angio-oedema and
death associated with the ACE inhibitor enalapril. S Afr
Med J. 2007 Apr;97(4):244-5