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Case report: Fentanyl-associated intraoperative anaphylaxis with pulmonary edema

[Étude de cas : Anaphylaxie peropératoire avec dème pulmonaire associé au fentanyl]

Kenneth C. Cummings, III, MD^* and Katherina Arnaut, CRNA

^* From the Departments of Regional Practice Anesthesiology, and
Outcomes Research,* The Cleveland Clinic, Cleveland, Ohio, USA.

Address correspondence to: Dr. Kenneth C. Cummings III, Department of Anesthesiology, Hillcrest Hospital, 6780 Mayfield Road, Mayfield Heights, Ohio 44124, USA. Phone: 440-312-3022; Fax: 440-312-6963; E-mail: cummink2{at}ccf.org

Purpose: To describe an atypical presentation of intraoperative anaphylaxis due to fentanyl.

Clinical features: A 40-yr-old otherwise healthy woman was admitted for abdominal hysterectomy. She denied any drug allergies or past adverse anesthetic reactions. Physical examination, vital signs, and laboratory findings were all within normal limits. Twenty minutes after induction of general anesthesia with propofol, lidocaine, fentanyl, and rocuronium, she developed sudden onset of hypotension and bronchospasm. She was treated with fluids and epinephrine, but nonetheless required mechanical ventilation for 48 hr. Chest x-ray revealed pulmonary edema which resolved over two days. She recovered completely and was discharged home. Subsequent skin testing showed reactions to fentanyl and succinylcholine. Because the patient had not received succinylcholine, the cause of her anaphylaxis was attributed to fentanyl. The patient later returned for her hysterectomy and tolerated spinal anesthesia with bupivacaine and morphine.

Conclusion: Anaphylaxis is a fulminant, unexpected, IgE-mediated allergic reaction which can be triggered by multiple agents. Common causative agents include neuromuscular blocking drugs, latex, antibiotics, colloids, hypnotics, and opioids. Fentanyl, however, is an extremely unusual cause of anaphylaxis. Pulmonary edema, although uncommon in anaphylaxis, can be a prominent feature, as was the case with this patient.

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