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Case report: Intraoperative anaphylactoid reaction and hydroxyethyl starch in balanced electrolyte solution (Hextend®)

[Présentation de cas : réaction anaphylactoïde peropératoire et amidon hydroxyéthylé dans une solution d’électrolyte balancée (Hextend®)]

Brian A. Hall, MD^*, Evangelo Frigas, MD, Damir Matesic, MD, Michael D. Gillett, MD and Juraj Sprung, MD PhD^*

^* From the Department of Anesthesiology, the
Division of Allergic Diseases and Internal Medicine, and the
Department of Urology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.

Address correspondence to: Dr. Juraj Sprung, Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA. Phone: 507-255-3298; Fax: 507-255-6463; E-mail: Sprung.juraj{at}mayo.edu

Purpose: To report a first case of probable anaphylactoid reaction to 6% hydroxyethyl starch reconstituted in balanced electrolyte and glucose solution (Hextend^®).

Clinical features: A 22-yr-old man was admitted for a partial nephrectomy. Near the end of the four-hour operation, an infusion of Hextend^® was initiated. Shortly thereafter, mechanical ventilation became difficult, peak inspiratory pressure increased to 55 cm H₂O with audible wheezing over the patient’s lungs. Blood pressure suddenly decreased to 68/46 mmHg. Multiple doses of phenylephrine, ephedrine and epinephrine were required to restore the patient’s blood pressure. Postoperatively, a diffuse urticarial rash was apparent on his upper torso. The patient recovered uneventfully. His postoperative serum tryptase was 26.3 ng·mL^–1 (reference range, < 11.5 ng·mL^–1) and the urine N-methyl-histamine was 2448 µg·g^–1 creatinine (reference range, 30–200 µg·g^–1 creatinine). Two months after the event, skin testing was conducted to test for possible allergy to latex, lidocaine, propofol, cisatracurium, succinylcholine, vecuronium, midazolam, fentanyl, ondansetron, neostigmine, and cephazolin, and all were negative. Hextend^® was also tested, starting with a 1:100,000 dilution and the results were negative.

Conclusions: The temporal relationship of severe hypotension, bronchospasm and skin rash within ten minutes from administration of Hextend^® in this patient suggests an immediate hypersensitivity reaction to hetastarch. The elevated levels of serum tryptase and urinary N-methyl-histamine suggest that this hypersensitivity was mediated from mast cell degranulation. Negative skin testing suggests that the reaction was anaphylactoid.