Case report: management of differential diagnosis and treatment of severe anaphylaxis in the setting of spinal anesthesia

Abstract

The purpose of this case report is to educate fellow anesthesiologists of a complicated differential diagnosis for sudden cardiovascular collapse after spinal anesthesia. We report a case where anaphylaxis occurred while under spinal anesthesia and resulted in difficult resuscitation. A 58-year-old woman undergoing bilateral knee replacements under spinal anesthesia experienced sudden seizure and cardiovascular collapse from acute anaphylactic shock while administering a cephalosporin. Local anesthetic toxicity, high spinal, and anaphylaxis were considered due to overlapping of symptoms. Successful resuscitation required prolonged advanced cardiac life support with substantially larger doses of epinephrine. Anaphylactic shock under spinal anesthesia is an acute and life-threatening complication, worsened by the spinal-induced sympathectomy, and aggressive resuscitation is warranted. Despite the presence of overlapping symptoms of differential diagnoses, rapid identification of the cause of cardiovascular collapse is crucial given that resuscitation treatment modalities may conflict. Timing of antibiotic administration should be adjusted for spinal anesthesia cases to allow time to detect possible anaphylaxis.

Keywords: Advanced cardiac life support; Anaphylactic shock; Cardiovascular collapse; Enhanced recovery after surgery; Local anesthetic systemic toxicity; Spinal anesthesia.