Low end-tidal CO2 as a real-time severity marker of intra-anaesthetic acute hypersensitivity reactions
A Gouel-Chéron, L de Chaisemartin, F Jönsson, P Nicaise-Roland, V Granger, A Sabahov, M-T Guinnepain, S Chollet-Martin, P Bruhns, C Neukirch, D Longrois, NASA study group, Philippe Montravers, Caitlin M Gillis, David A Mancardi, Michel Aubier, Caroline Sauvan, Marc Fischler, Julie Bresson, Catherine Paugam-Burtz, Skander Necib, Alexandre Mebazaa, Matthieu Le Dorze, Laurent Jacob, Carole Chahine, Hawa Keita-Meyer, Valentina Faitot, Olivier Langeron, Sabrine Roche, Bernard Cholley, Jean Mantz, A Gouel-Chéron, L de Chaisemartin, F Jönsson, P Nicaise-Roland, V Granger, A Sabahov, M-T Guinnepain, S Chollet-Martin, P Bruhns, C Neukirch, D Longrois, NASA study group, Philippe Montravers, Caitlin M Gillis, David A Mancardi, Michel Aubier, Caroline Sauvan, Marc Fischler, Julie Bresson, Catherine Paugam-Burtz, Skander Necib, Alexandre Mebazaa, Matthieu Le Dorze, Laurent Jacob, Carole Chahine, Hawa Keita-Meyer, Valentina Faitot, Olivier Langeron, Sabrine Roche, Bernard Cholley, Jean Mantz
Abstract
Background: Prompt diagnosis of intra-anaesthetic acute hypersensitivity reactions (AHR) is challenging because of the possible absence and/or difficulty in detecting the usual clinical signs and because of the higher prevalence of alternative diagnoses. Delayed epinephrine administration during AHR, because of incorrect/delayed diagnosis, can be associated with poor prognosis. Low end-tidal CO2 (etCO2) is known to be linked to low cardiac output. Yet, its clinical utility during suspected intra-anaesthetic AHR is not well documented.
Methods: Clinical data from the 86 patients of the Neutrophil Activation in Systemic Anaphylaxis (NASA) multicentre study were analysed. Consenting patients with clinical signs consistent with intra-anaesthetic AHR to a neuromuscular blocking agent were included. Severe AHR was defined as a Grade 3-4 of the Ring and Messmer classification. Causes of AHR were explored following recommended guidelines.
Results: Among the 86 patients, 50% had severe AHR and 69% had a confirmed/suspected IgE-mediated event. Occurrence and minimum values of arterial hypotension, hypocapnia and hypoxaemia increased significantly with the severity of AHR. Low etCO2 was the only factor able to distinguish mild [median 3.5 (3.2;3.9) kPa] from severe AHR [median 2.4 (1.6;3.0) kPa], without overlap in inter-quartile range values, with an area under the receiver operator characteristic curve of 0.92 [95% confidence interval: 0.79-1.00]. Among the 41% of patients who received epinephrine, only half received it as first-line therapy despite international guidelines.
Conclusions: An etCO2 value below 2.6 kPa (20 mm Hg) could be useful for prompt diagnosis of severe intra-anaesthetic AHR, and could facilitate early treatment with titrated doses of epinephrine.
Clinical trial registration: NCT01637220.
Keywords: anaesthesia; anaphylaxis; cardiac output; general; hypocapnia; neuromuscular blocking agents.
© The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com
Source: PubMed