SBH M

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SBH MMAngioneurotic oedema and ACE inhibitors

• Peter Sherren

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Airway scenario

• NOT EVERY SWOLLEN FACE IS ANAPHYLAXIS

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Introduction

• 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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Clinical History

• MP V?

• 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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Incident

• Unexpected complication of treatment.
• Unresponsive to steroids/anti-histamines/adrenalin
  e.
• 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 with trache insitu.

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Good practice points

• 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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Management problems

• 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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Learning points

• Causes of angioneurotic oedema
• 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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Recommendations

• In angioneurotic oedema (like burns)
• Use of size 10F bougie
• Use of uncut COETT
• Range of sizes of COETT ready for use
• Potential unique use of the Melker vs other large
  bore cricothyroidotomy kit
• Improvement/standardisation of difficult airway
  trolley in ED

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Discussion

• Choice of large bore cricothyroidotomy kit?
• CUFFED seldinger vs PCK vs Quicktrach II
• Place for selected pre-emptive cannula
  cricothyroidotomy and later use of Melker?

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References

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 2727181.
3. Cupido C, Rayner B. Life-threatening angio-oedema
   and death associated with the ACE inhibitor
   enalapril. S Afr Med J. 2007 Apr97(4)244-5